Saudi Journal of Gastroenterology
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   2017| May-June  | Volume 23 | Issue 3  
    Online since June 9, 2017

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The role of N-acetylcysteine in the treatment of non-acetaminophen acute liver failure
Anouar Teriaky
May-June 2017, 23(3):131-132
DOI:10.4103/sjg.SJG_621_16  PMID:28611335
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Role of N-acetylcysteine treatment in non-acetaminophen-induced acute liver failure: A prospective study
Tauseef Nabi, Sumaiya Nabi, Nadeema Rafiq, Altaf Shah
May-June 2017, 23(3):169-175
DOI:10.4103/1319-3767.207711  PMID:28611340
Background/Aims: Acute liver failure (ALF) is a rare but severe medical emergency. To date, there is no established treatment for non-acetaminophen-induced acute liver failure (NAI-ALF) other than liver transplantation, and little is known about the use of N-acetylcysteine (NAC) in NAI-ALF. A randomized case control study was conducted with the aim to determine the effect of NAC on the mortality of NAI-ALF patients, as well as to evaluate the safety and efficacy of NAC use. Patients and Methods: A total of 80 patients diagnosed with NAI-ALF were included in the study. Forty patients received NAC infusion for 72 h whereas the control group received placebo. The variables evaluated were demographic characteristics, signs and symptoms, biochemical parameters, and clinical course during hospitalization. Results: The two groups (NAC and control) were comparable for various baseline characteristics (such as etiology of ALF, INR, alanine aminotransferase, creatinine, albumin, and grade of encephalopathy), except for age. Although majority of patients had undetermined etiology (32.5% in NAC group and 42.5% in control group), the second main cause was acute hepatitis E and drug or toxin-induced ALF. The mortality decreased to 28% with the use of NAC versus 53% in the control group (P = 0.023). The use of NAC was associated with shorter length of hospital stay in survived patients (P = 0.002). Moreover, the survival of patients was improved by NAC (P = 0.025). Also, drug-induced ALF showed improved outcome compared to other etiologies. Conclusion: The findings of the study recommend the use of NAC along with conventional treatments in patients with NAI-ALF in non-transplant centers while awaiting referrals and conclude the use of NAC as safe.
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Prevalence and molecular characterization of hepatitis D virus in Saudi Arabia: A single-center study
Ghazi A Jamjoom, Mai M El-Daly, Esam I Azhar, Hind I Fallatah, Hisham O Akbar, Mohammed Babatin, Abdullah S Alghamdi, Mohammed I Dgdgi, Mohamed A Hamid, Yousef A Qari, Sherif A El-Kafrawy
May-June 2017, 23(3):176-182
DOI:10.4103/sjg.SJG_515_16  PMID:28611341
Background/Aims: Hepatitis D virus (HDV) is a defective RNA virus that is dependent on hepatitis B surface antigen (HBsAg) for transmission and replication. HDV significance arises from the possibility of poor prognosis of hepatitis B virus (HBV) infection. In Saudi Arabia, HDV prevalence varied from 8 to 32% before the HBV vaccination program and ranged from 0 to 14.7% after the vaccination program was started. The last study, performed in 2004, showed a prevalence of 8.6% in hospital-based HBV cases and 3.3% in healthy donors. The aim of this study was to investigate the prevalence and molecular characterization of HDV in chronic hepatitis B (CHB) patients at the King Abdulaziz University Hospital in Jeddah, Saudi Arabia by molecular and serological techniques. To the best of our knowledge, this is the first study to detect HDV at the molecular level in Saudi Arabia. Patients and Methods: The study included samples from 182 CHB patients from Jeddah; 13 samples with HBsAg negative were excluded. Samples were tested for HDV-Ab, viral RNA by reverse transcriptase–polymerase chain reaction (RT-PCR) in the HDV L-Ag region and sequence analysis. Results: The mean age of the participants was 44.36 years; 75.1% of the participants were Saudi nationals, 58% were males. Nine samples were positive for HDV-Ab and four were borderline; all were subjected to RT-PCR amplification. Three of the positive HDV-Ab cases and 1 borderline case were positive by RT-PCR. All the positive cases had HBV genotype D, and the positive RT-PCR cases were positive for HBV DNA. One of the HDV viremic samples was of genotype 1 by sequencing. The prevalence of HDV in the study was 7.7%, which was lower in Saudis (6.3%) than in non-Saudis (11.9%). Conclusion: HDV coinfection does not seem to have an effect on the clinical status of the recruited CHB cases in this study. More studies are needed to investigate the genetic diversity in other areas such as the southern parts of the Kingdom.
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Policy of screening for colorectal cancer in Saudi Arabia: A prospective analysis
Abdulrahman A Aljumah, Abdulrahman M Aljebreen
May-June 2017, 23(3):161-168
DOI:10.4103/sjg.SJG_468_16  PMID:28611339
Colorectal cancer (CRC) is one of the most common cancers worldwide. Several policies of CRC screening are available in different countries. The idea of screening is to identify patients at risk by detection of precancerous and small cancers early enough before they become advanced. In Saudi Arabia (SA), there is no countrywide policy for CRC screening despite the increasing incidence of the disease. Screening for CRC is a multidisciplinary approach that requires education programs, substantial financial support, several logistic measures, and predetermined resources before implementing such a program. We performed a prospective and systematic analysis of the of the screening policy of CRC in SA in view of high demand, anticipated development, and implementation of such a policy in the near future. We also attempted to investigate the justification for developing such a policy, as well as the difficulties, barriers, and opportunities that may be faced in its implementation. Further, we highlighted the current view of similar international screening policies. In this analysis, we adopted the framework for health policy analysis that examines four areas which may affect policy development, namely; content, context, process and actors.
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HBsAg clearance in chronic hepatitis B patients with add-on pegylated interferon alfa-2a to ongoing tenofovir treatment: A randomized controlled study
Hamad Al Ashgar, Musthafa C Peedikayil, Mohammed Al Quaiz, Fahad Al Sohaibani, Abdulrahman Al Fadda, Mohammed Q Khan, Einar Thoralsson, Sahar Al Thawadi, Ahmed Al Jedai, Khalid Al Kahtani
May-June 2017, 23(3):190-198
DOI:10.4103/sjg.SJG_541_16  PMID:28611343
Background/Aims: The ideal end point of treatment for chronic hepatitis B virus (HBV) infection is sustained off-therapy hepatitis B surface antigen (HBsAg) loss with or even without seroconversion to anti-HBs. We investigated the role of adding PEGylated interferon (PEG IFN) to ongoing tenofovir treatment in chronic HBV patients for achieving HBsAg clearance. Patients and Methods: In this randomized controlled trial, chronic HBV patients who have been receiving tenofovir for >6 months with HBV viral load <2000 IU/ml were randomized into two groups. One group (add-on therapy) was given subcutaneous PEG IFN 180 mcg weekly for 12 months in addition to tenofovir. Patients in the other group received only tenofovir 300 mg orally on a daily basis. Patients in both groups were followed up for a total of two years, and patients in both groups were given tenofovir 300 mg daily indefinitely until they developed HBsAg clearance. Results: Twenty-three patients were allocated to the PEG IFN and tenofovir (add-on therapy) group, and another 25 patients were recruited to the tenofovir monotherapy group. Before randomization, patients had received tenofovir for 1135 mean days (range203 to 1542 days). One patient (4.3%) in add-on therapy lost HBsAg and seroconverted. Within two years, mean HBsAg decreased significantly with add-on therapy (from 4753 IU/ml to 2402; P= 0.03); and it decreased from 5957 IU/ml to 4198; P= 0.09 in tenofovir monotherapy group. More patients in the add-on group developed serious side effects, with treatment discontinuation, and dose reductions (P = 0.3). Conclusion: PEG IFN and tenofovir add-on therapy was successful in achieving HBsAg clearance and seroconversion in 4.3% of the patients. Add-on therapy patients had a significant decrease in HBsAg levels in two years; and no significant decrease in HBsAg levels with the tenofovir monotherapy. With no significant HBsAg clearance, the utility of this combination regimen is questionable.
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Safety of non-anesthesia provider administered propofol sedation in non-advanced gastrointestinal endoscopic procedures: A meta-analysis
Basavana Gouda, Gowri Gouda, Anuradha Borle, Akash Singh, Ashish Sinha, Preet M Singh
May-June 2017, 23(3):133-143
DOI:10.4103/sjg.SJG_501_16  PMID:28611336
Background/Aims: The aim of the study was to evaluate the safety of non-anesthesia provider (NAPP) administered propofol sedation in patients undergoing non-advanced gastrointestinal (GI) endoscopic procedures. Materials and Methods: Pubmed, Embase, Cochrane central register of controlled trials, Scopus, and Web of Science databases were searched for prospective observational trials involving non-advanced endoscopic procedures. From a total of 608 publications, 25 [colonoscopy (9), upper GI endoscopy (5), and combined procedures (11)] were identified to meet inclusion criteria and were analyzed. Data was analyzed for hypoxia rates, airway intervention rates, and airway complication rates. Results: A total of 137,087 patients were involved. A total of 2931 hypoxia episodes (defined as an oxygen saturation below 90%) were reported with a pooled hypoxia rate of 0.014 (95% CI being 0.008-0.023). Similarly, pooled airway intervention rates and pooled airway complication rates were 0.002 (95% CI being 0.006–0.001) and 0.001 (95% CI being 0.000–0.001), respectively. Conclusions: The rates of adverse events in patients undergoing non-advanced GI endoscopic procedures with NAPP sedation are extremely small. Similar data for anesthesia providers is not available. It is prudent for anesthesia providers to demonstrate their superiority in prospective randomized controlled trials, if they like to retain exclusive ownership over propofol sedation in patients undergoing GI endoscopy.
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BRAF mutation is associated with poor clinicopathological outcomes in colorectal cancer: A meta-analysis
Yujie Li, Weier Li
May-June 2017, 23(3):144-149
DOI:10.4103/1319-3767.207712  PMID:28611337
Background/Aims: The clinical relevance of the BRAF mutation in colorectal carcinoma (CRC) remains controversial. We performed a comprehensive meta-analysis to evaluate the precise relationship of BRAF mutation to clinicopathological features. Materials and Methods: A systematic search of the electronic databases, including PubMed, the Web of Knowledge, and the China Journal Net was performed between January 2005 and December 2015. Outcomes of interest included gender, tumor site, tumor differentiation, node involvement, tumor size, and AJCC stage. We calculated the pooled odds ratios (ORs) or risk ratios with 95% confidence intervals (CIs) for each study using a random or fixed-effect model. Results: Twenty-five studies with a total of 13208 patients were included. BRAF mutation-positive CRC patients were 1464 (11.1%). Our meta-analysis revealed that, in patients with CRC, the BRAF mutation was associated with female, proximal site, poor differentiation, >5 cm size, and advanced AJCC stage. Conclusions: This meta-analysis demonstrated that BRAF mutation was closely related to adverse pathological features and poor outcome of CRC.
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Neuroblastoma amplified sequence gene mutation: A rare cause of recurrent liver failure in children
Mohammed Y Hasosah, Alaa I Iskandarani, Ayman I Shawli, Ashraf F Alsahafi, Ghassan A Sukkar, Mansour A Qurashi
May-June 2017, 23(3):206-208
DOI:10.4103/1319-3767.207714  PMID:28611345
Neuroblastoma amplified sequence (NBAS) gene mutation or infantile liver failure syndrome type 2 (ILFS type 2) is an extremely rare disease characterized by episodic liver failure precipitated by intercurrent febrile illness, and liver function recovering completely. Here, we report a 4-year-old girl with recurrent hepatitis. A diagnosis of ILFS type 2 was made based on NBAS mutation gene found by whole-exome sequencing. Our case provides a new insight toward considering NBAS mutation as a part of the differential diagnoses of any infant presenting with recurrent liver failure or hepatitis. We recommend sequencing NBAS in cases of recurrent hepatitis in infancy of unknown cause, especially in individuals with fever-associated hepatic dysfunction.
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Endoscopic retrograde cholangiopancreatography with double balloon enteroscope in patients with altered gastrointestinal anatomy: A meta-analysis
Xiao-Dong Shao, Xing-Shun Qi, Xiao-Zhong Guo
May-June 2017, 23(3):150-160
DOI:10.4103/1319-3767.207713  PMID:28611338
Background/Aims: The aim of this study was to evaluate the effectiveness and safety of endoscopic retrograde cholangiopancreatography with double balloon enteroscope (DBE-ERCP) in patients with altered gastrointestinal anatomy in a meta-analysis. Materials and Methods: A comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane library covering the period from January 2001 to December 2015. Data were selected and abstracted from eligible studies and were pooled using a random-effects model. Heterogeneity was assessed using the I2 test. Results: Ten studies involving a total of 301 patients were included in the analysis. The pooled enteroscopy, diagnostic, and therapeutic success rates were 89.75% [95% confidence interval (CI): 79.65–94.30%], 79.92% (95% CI: 68.06–89.59%), and 63.55% (95% CI: 53.70–72.86%), respectively. DBE-ERCP-related complications occurred in 18 patients including perforation (5), pancreatitis (3), cholangitis (9), and bleeding (1). The incidence of DBE-ERCP-related complication was 6.27% (95% CI: 2.61–11.38%). Conclusion: Diagnostic and therapeutic DBE-ERCPs are feasible in patients with altered gastrointestinal anatomy. DBE-ERCP may be considered when pancreaticobiliary diseases occur in patients undergoing Roux-en-Y reconstruction or pancreaticoduodenectomy.
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Plasma ghrelin and leptin in patients with inflammatory bowel disease and its association with nutritional status
Firas A Ghomraoui, Sami T Alotaibi, Meshal A Alharthi, Saeed S Asiri, Majid A Almadi, Othman R Alharbi, Nahla A Azzam, Abdulrahman M Aljebreen, Maria Saeed, Baraa Hajkhder, Waleed Saeed, Mohammad A Alzoghaibi
May-June 2017, 23(3):199-205
DOI:10.4103/sjg.SJG_575_16  PMID:28611344
Background/Aims: Ghrelin and leptin are thought to play a role in the loss of appetite in active inflammatory bowel disease (IBD). This study seeks to probe into the association of these markers with regards to IBD and the nutritional status of these patients. A case-control study was conducted between May 2015 and March 2016 at King Khalid University Hospital (KKUH). Thirty-one patients with IBD (both active and non-active) and forty-one healthy controls (both non-fasting and fasting) were recruited. Patients and Methods: Plasma ghrelin and leptin levels were determined using an enzyme immunoassay (EIA) technique. The nutritional status was determined through the standardized Mini-Nutritional Assessment (MNA) questionnaire. Results: The difference in the plasma ghrelin between active (263.7 pg/mL) and non-active (108 pg/mL) cases was significant (P= 0.02). The difference in mean plasma leptin level between active cases (229.4 pg/mL) vs. non-active cases (359.7 pg/mL) was insignificant (P= 0.4). In fasting (2028.6 pg/mL) and non-fasting controls (438.8 pg/mL), the mean plasma ghrelin values was significantly different (P< 0.01). In contrast, the plasma leptin level difference between fasting (727.3 pg/mL) and non-fasting (577 pg/mL) controls was insignificant (P= 0.14). There is a statistically significant association in mean ghrelin levels between the case group and the control group (P< 0.01). With regards to nutritional status, the mean MNA score of active cases compared to fasting controls was 18.8 ± 5 vs. 20.8 ± 3.8, respectively (P< 0.01) Conclusion: Ghrelin levels were lower in the active IBD cases compared to the inactive ones, signifying an underlying pathology as etiology to this phenomenon. Furthermore, ghrelin levels were significantly lower in both case groups compared to the controls. These findings, along with the disparity in the MNA scores, insinuate a possible link between hormone levels and the loss of appetite from which these patients suffer.
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Is plasma caveolin-1 level a prognostic biomarker in metastatic pancreatic cancer?
Nebi S Demirci, Mutlu Dogan, Gokmen U Erdem, Sabite Kacar, Turan Turhan, Saadettin Kilickap, Lutfi C Cigirgan, Ertugrul Kayacetin, Yakup Bozkaya, Nurullah Zengin
May-June 2017, 23(3):183-189
DOI:10.4103/sjg.SJG_483_16  PMID:28611342
Background/Aims: To evaluate the prognostic significance of plasma caveolin (CAV)-1 and its association with survival and treatment response rates in metastatic pancreatic cancer (MPC). Patients and Methods: Plasma samples were prospectively collected from 41 patients with newly diagnosed MPC. Moreover, plasma samples were collected from 48 patients with chronic pancreatitis and 41 healthy individuals (control groups) for assessing Cav-1 levels. Plasma Cav-1 levels were evaluated at baseline and after three cycles of chemotherapy in the patients with MPC. Results: The median Cav-1 level was 13.8 ng/mL for the patients with MPC and 12.2 ng/mL for healthy individuals (P = 0.009). The Cav-1 cut-off level was calculated as 11.6 ng/mL by using the receiver operating characteristic curve. The median overall survival and progression-free survival rates were 5 and 2.4 months, respectively, for participants with a high basal plasma Cav-1 level; the corresponding values were 10.5 and 9.4 months for participants with a low plasma Cav-1 level (P = 0.011 and P= 0.003, respectively). Of the 41 patients with MPC, 23 completed at least three cycles of chemotherapy. The median Cav-1 level was 13 ng/mL for post-treatment MPC (r2: 0.917; P= 0.001). High basal plasma caveolin-1 level have continued to remain at high levels even after chemotherapy, showing a trend toward worse response rates (P = 0.086). Conclusion: High basal plasma Cav-1 levels seem to be associated with poor survival and tend to yield worse therapeutic outcomes in patients with MPC. This study is the first to evaluate the prognostic significance of plasma Cav-1 levels as a prognostic factor in patients with MPC. However, larger prospective clinical trials are warranted.
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Erratum: Does combining liraglutide with intragastric balloon insertion improve sustained weight reduction?

May-June 2017, 23(3):211-211
DOI:10.4103/1319-3767.207738  PMID:28611347
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A rare etiology of idiopathic acute pancreatitis
Malay Sharma, Piyush Somani
May-June 2017, 23(3):209-210
DOI:10.4103/sjg.SJG_52_17  PMID:28611346
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