Saudi Journal of Gastroenterology
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   2009| July-September  | Volume 15 | Issue 3  
    Online since July 24, 2009

 
 
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IN FOCUS
Helicobacter pylori infection in developing countries: The burden for how long?
Barik A Salih
July-September 2009, 15(3):201-207
DOI:10.4103/1319-3767.54743  PMID:19636185
Approximately 50% (over 3 billion) of the world populations are known to be infected with Helicobacter pylori , mainly in the developing countries . Among those, hundreds of millions of people develop peptic ulceration during their lifetime and still tens of millions might progress to gastric cancer. Possible modes of H. pylori transmission generally described are through direct contact between family members and also through contaminated water and food. Because the high prevalence of infection occurs mainly in developing countries and because the test-and-treat strategy puts a huge economic burden on many of these countries, it is time to take an immediate action toward this bacterial infection and adopt a strategy to prevent it. To address this issue, an updated prevalence of infection, modes of transmission, economics of infection and preventative measures to block the infection process have been discussed.
  29 7,861 1,548
ORIGINAL ARTICLES
Crocetin reduces TNBS-induced experimental colitis in mice by downregulation of NFkB
Hamid A Kazi, Zhiyu Qian
July-September 2009, 15(3):181-187
DOI:10.4103/1319-3767.54750  PMID:19636180
Background/Aim: Ulcerative colitis (UC) is characterized by oxidative and nitrosative stress, leukocyte infiltration and upregulation of proinflammatory cytokines. In this study, we aim to investigate the effects of crocetin and its protective mechanism on 2,4,6- trinitrobenzene sulfonic acid (TNBS)-induced colitis in mice model. Materials and Methods: Intestinal lesions (judged by macroscopic and histological score) were associated with neutrophil infiltration (measured as increase in myeloperoxidase (MPO) activity in the mucosa), and high levels of malondialdehyde MDA (an indicator of lipid peroxidation). Results: Dose-response studies revealed that treatment of mice with crocetin (50 mg/kg/day) i.g. for 8 days) significantly ameliorated diarrhea and the disruption of colonic architecture. Higher and lower doses (100 and 25 mg/kg/day) did not exhibit comparable effects. In crocetin-treated mice, a significant reduction was noted in the degree of both neutrophil infiltration (measured as decrease in myeloperoxidase activity) and lipid peroxidation (measured as decrease in malondialdehyde activity) in the inflamed colon. Crocetin also reduced the levels of nitric oxide (NO) associated with the favorable expression of TH1 and TH2 cytokines and inducible NO synthase along with the down regulation of nuclear factor-kB (NFkB). Conclusion: These findings suggest that crocetin exerts beneficial effects in experimental colitis, and therefore we propose that this carotenoid may have therapeutic implications for human UC and can be administered along with the conventional therapy of UC
  11 4,927 1,025
Acute appendicitis: Is removal of a normal appendix still existing and can we reduce its rate?
Gamal Khairy
July-September 2009, 15(3):167-170
DOI:10.4103/1319-3767.51367  PMID:19636177
Background/Aim: To determine the incidence of negative appendectomies and to identify factors that may reduce the risk of having the normal appendices removed surgically. Design: Cross-sectional study. Setting: College of Medicine and King Khalid University Hospital, Riyadh, Saudi Arabia. Materials and Methods: The surgical and histological data of 852 patients who underwent appendicectomy were reviewed. All incidental or interval appendicectomies were excluded. Only patients who were admitted and whose appendices were removed and subjected to histology were included (585 patients). The data on patients who had a normal appendix on histology further analyzed to include demographics, specific investigations, operative findings of the appendix and additional operative findings that need other surgical procedures. Results: A normal appendix was removed in 54 (9.2%) of the patients. Only 5.5% of those patients had a computed tomography (CT) scan preoperatively and 3.7% had diagnostic laparoscopy. In 21 patients, additional operative and histological findings were obtained that might have caused the right lower abdominal pain. Conclusion: In spite of the advances in the diagnostic and imaging techniques, the rates of negative findings on appendicectomy have not decreased much. Clinical judgment is still the most important factor in the management of patients with suspected acute appendicitis. The routine use of CT scan or diagnostic laparoscopy for all patients who are suspected to have appendicitis is neither cost-effective nor safe.
  10 6,732 1,152
Protective effect of L-arginine against necrosis and apoptosis induced by experimental ischemic and reperfusion in rat liver
Pronobesh Chattopadhyay, Gunjan Shukla, Arun Kumar Wahi
July-September 2009, 15(3):156-162
DOI:10.4103/1319-3767.45356  PMID:19636175
Background/Aim: To study the effect of L-arginine on apoptosis and necrosis induced by 1-h ischemia followed by 3-h reperfusion. Materials and Methods: Adult Wistar rats underwent 60 min of partial liver ischemia followed by 3-h reperfusion. Eighteen Wistar rats were divided into sham-operated control group (I) ( n = 6), ischemia and reperfusion (I/R) group (0.9 % saline (5 mL/kg, orally) for 7 days) (II) ( n = 6), and L-arginine-treated group (10 mg/kg body weight daily orally for 7 days before inducing ischemia-reperfusion maneuver) (III) ( n = 6). Apoptotic and necrotic hepatocytes, nitric oxide levels in hepatocytes, Bcl-2 mRNA, and Bcl-2 protein were measured. Liver injury was assessed by plasma alanine transaminases (ALT), aspartate transaminases (AST), liver histopathology, and electron microscopy. Results: An ischemic and reperfusion hepatocellular injury occurred as was indicated by increased serum ALT, AST, histopathology, and electron microscopy. Apoptosis and necrosis associated marker gene Bcl-2 mRNA and protein expression were decreased in I/R group. Pretreatment with L-arginine significantly decreased serum ALT and AST level and apoptotic and necrotic cells after 1 h ischemia followed by 3 h of reperfusion. Nitric oxide production in hepatocytes was increased twofold by L-arginine treatment when compared with I/R group. Histopathology and transmission electron microscopy (TEM) studies showed markedly diminished hepatocellular injury in L-arginine-pretreated rats during the hepatic I/R. Conclusion: Thus, it may be concluded that L-arginine afforded significant protection from necrosis and apoptosis in I/R injury by upregulated Bcl-2 gene and nitric oxide production.
  9 4,762 952
A survey of surgical management of acute cholecystitis in eastern Saudi Arabia
Abdulmohsen A Al-Mulhim
July-September 2009, 15(3):176-180
DOI:10.4103/1319-3767.54748  PMID:19636179
Background/Aim: It is now 60 years since early cholecystectomy was advocated for acute cholecystitis (AC). Yet, surgical opinion remains divided regarding its optimal timing. Furthermore, recent surveys have shown low utilization of early laparoscopic cholecystectomy (LC) for AC. Aim: This survey aimed to assess the current management of AC in Eastern Saudi Arabia. Materials and Methods: A postal survey was conducted by means of a questionnaire sent to 95 surgeons practicing LC. The questionnaire addressed the surgical management of AC in relation to the subspecialty of interest, duration of consultant status, number of cholecystectomies performed per year, and the percentage performed laparoscopically. Results: There were 87 responders (92%); two were excluded from the analysis for different reasons. Early LC was preferred by 71% of the responders. With regard to the timing of LC, there was no significant difference in relation to the surgeon's subspecialty of interest or duration of consultant status. However, increased number of cholecystectomies and percentage of cholecystectomies performed with a laparoscopic approach were significantly associated with early LC. Conclusion: Early LC for AC is practiced by th e majority of surgeons in Eastern Saudi Arabia. This practice is significantly associated with increased number of cholecystectomies performed as well as with the percentage performed with a laparoscopic approach. According to the current literature, early LC for AC results in a shorter total hospital stay and reduced cost of treatment.
  9 3,287 622
BRIEF COMMUNICATION
Solitary rectal ulcer syndrome: A clinicopathological study of 13 cases
Nabeel Al-Brahim, Naser Al-Awadhi, Saleh Al-Enezi, Saqer Alsurayei, Mahmoud Ahmad
July-September 2009, 15(3):188-192
DOI:10.4103/1319-3767.54749  PMID:19636181
Background/Aims: Solitary rectal ulcer syndrome (SRUS) is a rare disorder that has a wide spectrum of clinical presentation and variable endoscopic findings. To further characterize the clinical and pathological features, a retrospective, hospital-based clinicopathological study was conducted. Materials and Methods: All cases of SRUS diagnosed at Farwania Hospital, Kuwait, between 2002 and 2007 were retrieved from the computerized filing system. The histological slides were reviewed by two authors to confirm the diagnosis. Immunohistochemical stain for smooth muscle actin (SMA) was performed. The clinical files were reviewed for clinical features and endoscopic findings. Results: Thirteen cases were identified: 8 males and 5 females. The age range was 15-85. Rectal bleeding, constipation, and abdominal pain were the most common presenting symptoms and were seen, either alone or in various combinations, in 12 of the 13 cases. Rectal ulceration was the most common endoscopic finding, being seen in 9 of the13 cases; 3 of these cases had multiple ulcerations. Two patients had rectal polyps, with one of them having multiple polyps. The histological examination revealed surface serration, fibromuscular obliteration of the lamina propria, and crypts' distortion in all the cases. Seven of the cases had diamond crypts. Ectatic mucosal vessels were a common finding. Positivity for SMA in the lamina propria was seen in all examined cases. Conclusion: SRUS is a rare disorder and only 13 cases were diagnosed in Farwania hospital over a 6-year period. The clinical presentation of our patients was variable. The presence of polyps and multiple ulcerations on endoscopy is further evidence that SRUS is a misnomer. Surface serration, fibromuscular obliteration, and crypts' distortion are the most characteristic features. The presence of diamond crypts is an additional diagnostic feature.
  6 5,845 780
CASE REPORTS
Esophageal trachealization: A feature of eosinophilic esophagitis
Abdulrahman A Al-Hussaini, Toufic Semaan, Imad A El Hag
July-September 2009, 15(3):193-195
DOI:10.4103/1319-3767.54747  PMID:19636182
Eosinophilic esophagitis (EE) is an inflammatory condition characterized by intense eosinophilic infiltration of the esophagus. EE is frequently misdiagnosed as gastroesophageal reflux disease. Here, we present a child with EE and a characteristic endoscopic finding, "ringed esophagus". An 11-year-old Saudi boy presented with dysphagia for 1 year. He had experienced an intermittent sensation of solid food sticking in his chest, which was relieved by drinking liquids. A barium swallow excluded anatomical causes of dysphagia, but revealed multiple-ringed esophagus. Endoscopy showed a furrowing and trachealizing appearance of the entire esophagus. Hisologically, extensive eosinophilic infiltration was a feature in biopsies obtained from the esophagus. The child responded well to a 2-month course of inhaled fluticasone. Symptoms recurred 3 months after discontinuation of therapy, which necessitated resumption of inhaled fluticasone. The endoscopic appearance of multiple esophageal rings should raise suspicion of EE and be confirmed by esophageal biopsies.
  6 6,865 653
REVIEW ARTICLE
Acute biliary pancreatitis: Diagnosis and treatment
Zakaria M Hazem
July-September 2009, 15(3):147-155
DOI:10.4103/1319-3767.54740  PMID:19636174
Gallstones are the commonest cause of acute pancreatitis (AP), a potentially life-threatening condition, worldwide. The pathogenesis of acute pancreatitis has not been fully understood. Laboratory and radiological investigations are critical for diagnosis as well prognosis prediction. Scoring systems based on radiological findings and serologic inflammatory markers have been proposed as better predictors of disease severity. Early endoscopic retrograde cholangiopancreatography (ERCP) is beneficial in a group of patients with gallstone pancreatitis. Laparoscopic cholecystectomy with preoperative endoscopic common bile duct clearance is recommended as a treatment of choice for acute biliary pancreatitis. The timing of cholecystectomy, following ERCP, for biliary pancreatitis can vary markedly depending on the severity of pancreatitis
  6 21,798 3,427
ORIGINAL ARTICLES
Retrospective study of the clinical profile and prognostic indicators in patients of alcoholic liver disease admitted to a tertiary care teaching hospital in Western Nepal
Om K Pathak, Raju Paudel, Om B Panta, Hom P Pant, Bishnu R Giri, Baikuntha Adhikari
July-September 2009, 15(3):171-175
DOI:10.4103/1319-3767.54746  PMID:19636178
Background/Aim: Alcohol is the most common substance abused in Nepal. Liver disease caused by alcohol abuse, including its end stage, cirrhosis, is a major health care problem, which is difficult to treat. Objectives: To study the demographic profile, laboratory parameters, complications and their prognostic implications among patients of alcoholic liver disease (ALD). Materials and Methods: Records of all patients of ALD admitted from January1 , 2005 to December 31 , 2006 were studied and followed up to December 31, 2007. A total of 181 patients were analyzed. Their clinical profile and laboratory parameters were noted and analyzed using SPSS-10.0 software. Results: Among the 181 patients, 80.7% were male, 30.9% were army/ex-army and 65.2% were documented smokers. The mean age of presentation was 52.08 years. Jaundice (57.5%) was the most common presentation followed by hepatomegaly (51.4%). Hypoalbuminemia (50.3) followed by ascites (48.1) were common complications. Death occurred in 19.1% of the patients, the most common cause being hepatic encephalopathy (72.2%) followed by variceal bleeding and hepatorenal syndrome. Jaundice, ascites and hepatic encephalopathy at presentation and female sex were significantly associated with increased mortality along with discriminant score >32, aspartate aminotransferase (AST): Alanine aminotranferase (ALT) ≥ 2, ultrasonography (USG)-proven cirrhosis, rise in prothrombin time ≥5 s, total bilirubin ≥ 4 mg/dL and ESR ≥34. Conclusion: ALD was predominantly seen among the productive age group with a high morbidity and mortality. Jaundice, ascites, hepatic encephalopathy at presentation and female sex are poor prognostic indicators along with discriminant score > 32, AST:ALT ≥ 2, USG-proven cirrhosis, coagulopathy, hyperbilirubenemia and high ESR.
  5 5,178 766
CASE REPORTS
Squamous cell carcinoma of the rectum 21 years after radiotherapy for cervical carcinoma
Kevin K Leung, Joseph Heitzman, Anand Madan
July-September 2009, 15(3):196-198
DOI:10.4103/1319-3767.54745  PMID:19636183
Squamous cell carcinoma (SCC) of the rectum is an extremely rare malignancy, accounting for 0.1-0.2% of rectal malignancies. It is associated with ulcerative colitis, prior radiation, schistosomiasis, ovarian cancer, endometrial cancer, human papilloma virus, colocutaneous fistulas and colonic duplication. Prior reported cases of SCC of the rectum have involved treatment with brachytherapy and external beam radiation. This case is particularly interesting because of the remote exposure of radiation (21 years previously) and the subsequent development of SCC of the rectum. Although extremely rare, SCC of the rectum can occur decades after radiation exposure.
  4 5,587 680
NEW HORIZON
Growth factors as treatment for inflammatory bowel disease: A concise review of the evidence toward their potential clinical utility
Josue Barahona-Garrido, Jorge Hernandez-Calleros, Ignacio Garcia-Juarez, Jesus K Yamamoto-Furusho
July-September 2009, 15(3):208-212
DOI:10.4103/1319-3767.54742  PMID:19636186
In the process of inflammation and repair of the intestinal mucosa in inflammatory bowel disease (IBD), there occurs a complex and an unknown interplay of innate and adaptive immune mechanisms. This interaction of factors may explain why IBD is characterized by a relapsing and remitting clinical course. Different components of innate immunity, hormones and interleukins in IBD have been suggested to be impaired. The growth hormone, epidermal growth factor, keratinocyte growth factor and colony-stimulating factors have emerged as potential tools for the modulation of intestinal inflammation and repair. Despite promising results of initial studies, the evidence that justify treatment of patients in clinical practice is not enough as some of the trials are nonrandomized or included a small number of patients. In this concise review, we provide a summary of the most recent and relevant evidence regarding the potential therapeutic effects of growth factors in IBD.
  1 4,145 712
ORIGINAL ARTICLES
Stapled hemorrhoidopexy: The Aga Khan University Hospital Experience
Ali Athar, Tabish Chawla, Pishori Turab
July-September 2009, 15(3):163-166
DOI:10.4103/1319-3767.45358  PMID:19636176
Background: Stapled hemorrhoidopexy for prolapsing hemorrhoids is conceptually different from excision hemorrhoidectomy. It does not accompany the pain that usually occurs after resection of the sensitive anoderm. This study was carried out to evaluate the clinical outcome of stapled hemorrhoidopexy at The Aga Khan University Hospital. Methods: A sample of 140 patients with symptomatic second-, third-, and fourth-degree hemorrhoids and circumferential mucosal prolapse underwent stapled hemorrhoidopexy from July 2002 to July 2007. They were evaluated for postoperative morbidity, analgesic requirement, and recurrence. Results: Seventy-eight percent were males and the mean age was 45 (range 16-90) years. The mean operative time was 35 (15-78) min. The mean parenteral analgesic doses during the first 24 h were 2.1. All patients received oral analgesics alone after 24 h. No significant postoperative morbidity was observed. The mean in-patient hospital stay was 1.3 (0-5) days. Patients were followed-up for 24 (range, 2-48) months. Minor local recurrence of hemorrhoids was seen in four patients and was managed by band ligation. Conclusion: Stapled hemorrhoidopexy procedure was found safe, well tolerated by patients with minimal parenteral analgesic use and early discharge from the hospital.
  1 6,633 945
LETTER TO THE EDITOR
Biliary cystadenoma mimicking hydatid cyst
MH Raza, AZ Rab, Shehtaj Khan, Reyaz Ahmad
July-September 2009, 15(3):199-200
DOI:10.4103/1319-3767.54744  PMID:19636184
  - 2,165 439
RADIOLOGY QUIZ
Bleeding per rectum in a patient with an amputated finger
Aijaz Hakeem, Hakim Shafi, Shubana Rasool, Muneer Ahmad
July-September 2009, 15(3):213-214
DOI:10.4103/1319-3767.54741  PMID:19636187
  - 1,974 414
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