Saudi Journal of Gastroenterology
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ABSTRACTS  
Year : 2020  |  Volume : 26  |  Issue : 8  |  Page : 41-64
SDDF 2020



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Date of Web Publication9-Oct-2020
 

How to cite this article:
. SDDF 2020. Saudi J Gastroenterol 2020;26, Suppl S2:41-64

How to cite this URL:
. SDDF 2020. Saudi J Gastroenterol [serial online] 2020 [cited 2020 Nov 24];26, Suppl S2:41-64. Available from: https://www.saudijgastro.com/text.asp?2020/26/8/41/297661





   Abstract SJG2020/01: Genotype Distribution at IL28B RS12979860 Polymorphism in Apparent Healthy Bangladeshi Population Top


Abu Saleh Mohammad Sadequl Islam, Mamun Al Mahtab, Salimur Rahman

Shaheed Ziaur Rahman Medical College, Bogra, Bangladesh

E-mail: [email protected]

Background: The rs12979860 single-nucleotide polymorphism (SNP) is only 3 kb upstream of the IL28B gene, which encodes the type III interferon (IFN-?), and the genes encoding these molecules are clustered on human chromosome 19q13. They are structurally related to the interleukin-10 superfamily of cytokines induced by viral infections, signal through the JAK–STAT and MAPK pathways, and exhibit antiviral activity in vitro and in vivo models, including hepatitis C virus (HCV) and HBV. We evaluate the rs12979860 SNP genotype in IL28B in apparently healthy Bangladeshi population. Methods: Single SNP in the IL28B gene (rs12979860C/T) was examined in 30 healthy controls. This study was done in the Department of Hepatology, BSMMU, Dhaka. The polymorphism of IL28B rs12979860 was analyzed by a genotyping technique, based on polymerase chain reaction followed by restriction enzyme analysis in the Department of Immunology, BSMMU. Patients having infection with hepatitis B core or HCV, alcohol abusers (>20 g/day), and patients aged under 18 years were excluded. Results: There were 33.3% males and 66.7% females. The mean age was 46.2 (±11.4) years with a range from 28 to 70. None having either family history of liver disease or history of known liver disease was present. The frequency of CC, CT, and TT was 70%, 30%, and 0%, respectively, in healthy controls. Carrier of the minor C allele in rs12979860 was 85%. Conclusions: Our results suggest that the C allele and non-CC which referred to favorable genotypes are predominant in apparent healthy Bangladeshi population.


   Abstract SJG2020/02: Chronic Granulomatous Disease with Liver Abscess in Young Male: A Case Report Top


Oweida Aldoseri, Khulood AlJohani, Rana Almosa

Department of Medicine, Gastroenterology Unit, King Fahd Medical City, Riyadh, Saudi Arabia

E-mail: [email protected]

Case Report: Chronic granulomatous disease (CGD) is an inherited primary immunodeficiency caused by functional impairment of the nicotinamide adenine dinucleotide phosphate oxidase complex in neutrophilic granulocytes and monocytes and characterized by recurrent and severe infections, dysregulated inflammation, and autoimmunity. We report the case of an 18-year-old Saudi male, medically free with a stunted growth admitted to the Hepatobiliary Department at King Fahad Medical City in Riyadh, Saudi Arabia, in December 2018 as a case of liver abscesses with right-sided pleural effusion based on abdominal computed tomographic scan findings for drainage. The culture grew community-acquired methicillin-resistant Staphylococcus aureus. Discussion: A literature review was conducted using the databases PubMed and Google Scholar for the incidence rate of CGD in Saudi Arabia. Up to our knowledge, few cases were reported and all of them were in a young female. In general, patients with X-linked CGD have a more severe disease course with earlier age at presentation and earlier age of death. Herein, we report case of an 18-year-old male with CGD who had unusual clinical presentation and unexpectedly good outcome which considered as the first case of CGD in the adult male.


   Abstract SJG2020/03: Clinical Outcomes of Treatment Modalities of Hepatocellular Carcinoma: An Experience from Saudi Arabia Top


Yaser M. Dahlan, Bader H. Shirah, Abdullah S. Alghamdi

Department of Medicine, Gastroenterology Unit, King Abdulaziz Medical City, Jeddah, Saudi Arabia

E-mail: [email protected]

Background: Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver. Most patients with HCC are unsuitable for surgical therapies. Therefore, nonsurgical therapies play a central role in the management of this disease. Several percutaneous treatment modalities are available for HCC, including radiofrequency ablation (RFA), transarterial chemoembolization (TACE), and transarterial radioembolization (TARE). In this study, we aim to evaluate the clinical outcomes, morbidity and mortality rates, and survival rates of four treatment modalities for HCC (RFA, TACE, TARE, and sorafenib) and compare the success rate of each modality. Methods: A retrospective observational study was conducted at King Abdulaziz Medical City in Jeddah, Saudi Arabia. The inclusion criteria were composed of patients diagnosed with HCC who are currently receiving or received RFA, TACE, TARE, or sorafenib treatments in the past between 2008 and 2017. The primary outcome of this study was the proportion of disease-free patients at the last follow-up (cure of HCC). Results: A total of 108 patients were included in our study. The mean age of the patients was 67 ± 10 years. Eighty-two patients (75.9%) underwent interventions with intention to cure or to stabilize HCC, while 26 patients (24.1%) were started on sorafenib as a palliative treatment. The cure rates were 41.2% with RFA, 40% with the combination of TACE and RFA, 23.3% with TACE, and 4% with TARE. All patients on sorafenib died from advanced-stage HCC. Conclusion: The results of our single-center study from Saudi Arabia provide further evidence for the efficacy of several treatment modalities for the management of HCC in the clinical practice setting. RFA and the combination of TACE and RFA showed superior outcomes with a cure rate reaching up to 40%. TARE showed a low cure rate. Sorafenib continues to be an important palliative treatment but does not offer a cure potential.


   Abstract SJG2020/04: Hepatitis B Virus Reactivation Rate Among Inflammatory Bowel Disease Patients on Tumor Necrosis Factor Inhibitors with HepatitiS B Core Antibody Positive and Surface Antigen Negative: A Multi-Center, Retrospective Cohort Study Top


Eman Al Sulais, Raed Alsulaiman, Mais AlSardi, Mohamad Bakro, Turki AlAmeel1,2

Department of Medicine, Royal Commission Hospital, Jubail, 1Department of Medicine, King Fahad University Hospital, Khobar, 2Department of Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia

E-mail: [email protected]

Background: Tumor necrosis factor inhibitors (TNFis) act on blocking TNF-a, a pro-inflammatory cytokine, which plays a vital role in enhancing hepatitis B virus (HBV) clearance. Thus, blocking TNF-a may augment viral replication. The standard of care in inflammatory bowel disease (IBD) patients with hepatitis B surface antigen (HBsAg) positive requiring TNFi is to give prophylactic antiviral agents. Nonetheless, the approach in patients with HbsAg negative and hepatitis B core antibody (HBcAb) positive is varied. The ECCO and EASL recommend active monitoring of liver enzymes and serological markers, while the AGA recommends antiviral prophylaxis over monitoring. In this study, we aimed to determine the outcome of IBD patients on TNFi with HbsAg negative and anti-HbcAbs who are not receiving prophylactic therapy. Methods: The primary endpoint was the development of any episode of viral and/or clinical reactivation after starting TNFi. The viral reactivation was defined as reverse seroconversion to positive HbsAg. The clinical reactivation was defined as ALT > upper limit of normal and/or clinical evidence of acute hepatitis. Results: A total of 440 patients were screened. Seven patients met the inclusion criteria. Mean age of the patients was 40.4 years. 42.9% were on infliximab, 42.9% on adalimumab, and 14.3% on certolizumab. Regarding concomitant drugs, 14.3% was on steroids, 28.6% were on 5-amino salicylic acid, and 71.3% were on azathioprine. None of the patients developed clinical or viral reactivation during the study period [Table 1]. Conclusion: This study supports the safety of active monitoring of liver enzymes and serological markers for IBD patients on TNFi as recommended by the ECCO and EASL guidelines.
Table 1: Baseline demographics, viral and serological markers pre- and post-tumor necrosis factor inhibitors

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   Abstract SJG2020/05: Use of Complementary and Alternative Medicine By Saudi Inflammatory Bowel Disease Patients Top


Mahmoud Mosli, Albaraa Altunisi, Mazen Banweer, Faris Arif, Yousif Qari

Department of Medicine, College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia

E-mail: [email protected]

Background: Inflammatory bowel disease (IBD) is a chronic autoimmune disease that results in ongoing inflammation in the gastrointestinal tract and can lead to long-term complications. Treatments for IBD target inflammation and include biologics and immunosuppressants, which are associated with significant adverse effects. Nonresponse to biologics occurs in up to 50% of treated patients. As such, patients turn to alternative methods of treatment such as complementary and alternative medicine (CAM). We aimed to examine the prevalence of CAM use in Saudi patients diagnosed with IBD. Methods: We conducted a cross-sectional study of patients with IBD seen at the outpatient department of King Abdulaziz University Hospital, Jeddah, Saudi Arabia, between October 2019 and October 2020. Adult patients diagnosed with UC or CD were identified and surveyed. Clinical, laboratory, endoscopic, radiologic, and histologic data were collected. The patients completed a detailed questionnaire focusing on CAM use. Descriptive statics was calculated; for quantitative variables, means, standard deviations, and minimum and maximum values or medians with interquartile ranges were summarized, where appropriate; and for qualitative variables, we used frequencies measurement. The prevalence of CAM use was calculated using the standard prevalence formulae. Logistic regression was used to investigate the associations between patient demographics, clinical features, complications, and CAM use. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported using a P = 0.05 as a statistically significant level. Results: A total of 71 IBD patients were surveyed, of which 75% had CD. Severe symptoms were reported by 54% of the patients and 48% were on biologic treatment. Ninety percent of this cohort reported using some form of CAM, of which 78% used them within the past year and 52% reported having a positive effect to CAM treatment. Thirty-four percent of the patients reported using CAM therapy without the knowledge of their treating physician. The most common route of acquiring CAM was through relatives (66%), and the most common form of CAM used was honey (62%), Zamzam water (54%), and physical activity (32%). Logistic regression analysis did not identify any statistically significant predictors of CAM use in this cohort of patients. Conclusions: CAM use is extremely common among Saudi patients with IBD. The majority of patients seem to turn to CAM use when their symptoms are severe and appear to be influenced by cultural tradition in their decision to use CAM rather than advice given by their treating physician.


   Abstract SJG2020/06: Risk of Neutropenia in Inflammatory Bowel Disease Patients Treated with Tumor Necrosis Factor InhibitorS: A Single-Center, Retrospective Cohort Study Top


Mais AlSardi, Dimah AlAskar, Eman Al Sulais1, Mahmoud Mosli2, Turki AlAmeel

Department of Medicine, King Fahad Specialist Hospital, Dammam, 1Department of Medicine, Royal Commission Hospital, Jubail, 2Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia

E-mail: [email protected]

Background: Tumor necrosis factor (TNF) inhibitors (TNFis) have become the mainstay of treatment in moderate-to-severe cases of inflammatory bowel disease (IBD). Neutropenia has been reported in patients receiving TNFi for IBD and other diseases. In this study, we aim to ascertain the relationship between the use of TNFi and the development of neutropenia in IBD patients. Methods: This is a retrospective cohort study including all adult IBD patients receiving TNFi at a tertiary care center over an 11-year period. The primary outcome was the development of any neutropenic episode after starting a TNFi. For our secondary outcomes, we evaluated the impact of concomitant use of 5-amino salicylic acid (5-ASA) or an immunomodulator on the risk of developing neutropenia. Results: The final analysis included 281 patients. of those included, 34.2% developed at least one episode of neutropenia while on a TNFi. The majority of these episodes (67.7%) were mild with ANC between 1000 and 1500/mm3. There was no significant difference in the age, gender, agent used, or type of IBD between those who developed neutropenia and those who did not. Concomitant use of azathioprine (odds ratio [OR] = 2.32, 95% confidence interval [CI]: 1.26–4.28; P = 0.007) or 5-ASA (OR = 3.15, 95% CI: 1.55–6.39; P = 0.001) was the significant independent predictor of developing neutropenia. Conclusions: In this study, mild neutropenia was common among IBD patients on TNFi. Future prospective studies are required to further clarify the significance of neutropenia in IBD patients receiving TNFi.


   Abstract SJG2020/07: Prevalence and Clinical Predictors of Restless Leg Syndrome in Inflammatory Bowel Disease Patients Top


Mahmoud Mosli, Lujain Bukhari, Alya Khoja, Nuha Ashour, Hadeel Aljahdali, Ohood Khoja, Yusuf Qari

Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia

E-mail: [email protected]

Background: Inflammatory bowel disease (IBD) is a chronic inflammatory disorder that causes inflammation and ulceration in the gastrointestinal tract. Anemia is a common manifestation of IBD and can be secondary to iron deficiency, folate (folic acid) deficiency, or Vitamin B12 deficiency. Iron deficiency anemia has been reported to be associated with restless leg syndrome (RLS). This study aimed to explore the prevalence, clinical predictors, and severity of RLS in IBD patients compared to healthy individuals. Methods: We conducted a case–control study comparing controls with IBD patients seen at the outpatient department of King Abdulaziz University Hospital, Jeddah, Saudi Arabia, between October 2019 and October 2020. All patients diagnosed with UC or CD were identified and included. Diagnosis of CD and UC was based on the standard criteria. Assessment of RLS was performed using the Restless Leg Syndrome Questionnaire (RLSQ). All criteria must have been met to diagnose RLS. An RLS severity score that ranges from 0 to 40 was used. Descriptive statics was calculated; for quantitative variables, means and standard deviations were summarized; and for qualitative variables, we used frequencies measurement. The prevalence of RLS in both cases and control groups was calculated. Logistic regression was used to investigate an association between patient demographics, clinical features, complications, and RLS. Odds ratios (ORs) with 95% confidence intervals were reported using a P = 0.05 as a statistically significant level. Results: A total of 219 IBD patients and 219 healthy controls were obtained. The mean age was 30.2 ± 11.7 years and 64% were females. The majority of participants did not smoke (77%) and did not have a family history of IBD (92%). RLS criteria were fulfilled in only 8% of the participants and did not differ between IBD patients and controls (8.3% vs. 7.6%, P = 0.81). The majority of the participants with RLS had mild (36%) or moderate (39%) RLS based on the RLSQ severity score. According to logistic regression analysis, age (OR = 1.03, P = 0.02), B12 deficiency (OR = 4.1, P = 0.03), varicose veins (OR = 6.1, P = 0.03), and habitual foot tapping (OR = 8.7, P = 0.02) were associated with RLS diagnosis, while Vitamin B12 deficiency (OR = 6.7, P < 0.0001) and habitual foot tapping (OR = 18, P = 0.02) were associated with more severe forms of RLS. Female gender (OR = 0.29, P < 0.0001) appeared to be protective against severe RLS. Conclusion: In this cohort of Saudi patients with IBD, the prevalence of RLS did not occur more commonly among IBD patients compared to healthy controls.


   Abstract SJG2020/09: Bowel Damage Assessed by the Lemann Index in Saudi Patients at the Time Of Crohn'S Diagnosis Top


Hajar Halawani1,2, Ahmed Abduljabbar1,2, Mohammad Wazzan1,2, Dalia Hashim1,2, Cedric Baumann3, Amandine Luc3, Laurent Peyrin-Biroulet4, Mahmoud Mosli1,2

Departments of 1Medicine and 2Radiology, King Abdulaziz University, Jeddah, Saudi Arabia, 3Clinical Research Support Facility, Methodological and Statistical Unit, University Hospital of Nancy, France, 4Department of Gastroenterology, Nancy University Hospital, France

E-mail: [email protected]

Background: The natural history of Crohn's disease (CD) may be different in Arabic countries compared to Europe and North America. The degree of bowel damage in these patients at the time of diagnosis is unknown. Lemann index (LI) is an instrument used to measure the cumulative digestive tissue damage in patients with CD. We assessed for the first time the degree of bowel damage at the time of Crohn's diagnosis using the LI in Saudi Arabia. Methods: This retrospective study was conducted by reviewing the data of all CD patients following at King Abdulaziz University Hospital (KAUH) who underwent endoscopy and MRE at diagnosis. A LI >2.0 was used as a cutoff point for bowel damage as previously described. Results: Eighty-three patients with CD were included. Forty-one were males and the median age was 27 years. with regard to CD location and extension, 34.9% showed ileal disease (L1), 9.6% showed colonic CD (L2), whereas 55.4% had ileocolonic involvement (L3). Moreover, 48.2% of the patients presented with a noncomplicated behavior (B1), 25.3% had at least one stricture (B2), and 26.5% showed a penetrating phenotype (B3). Median disease duration from diagnosis to baseline MRE was 8 months. Perianal CD was observed in 2.4% of subjects and 62.7% underwent bowel resection. Mean LI was 2.4 (standard deviation ± 2.6), with 34 patients (41%) exhibiting a LI score indicative of bowel damage at the time of diagnosis. Conclusion: A significant proportion of patients with CD present with advanced bowel damage at the time of diagnosis in Saudi Arabia.


   Abstract SJG2020/10: An Evaluation of Appropriateness of Albumin Use in Adult Patients at International Medical Center Hospital Top


Radia Hamameh, Hatem Bayoumy, Husam Al Thobaiti, Ali Saber

Department of Pharmacy, International Medical Center, Jeddah, Saudi Arabia

E-mail: [email protected]

Background: Human albumin solution is widely used in clinical practice, it can be used appropriately to correct interstitial pulmonary edema and hypoproteinemia associated with acute respiratory distress syndrome, in the treatment of hypovolemia, and it is recommended over crystalloids in certain settings, such as large-volume paracentesis, hepatorenal syndrome, and spontaneous bacterial peritonitis treatment. Or it can be used inappropriately like in case of nutritional interventions, to correcting hypoalbuminemia, in hemodialysis, and with diuretic to improve urine output. The aim of this study was to determine the appropriateness of albumin indications and dosing within 3 months and to assess the cost that associated with inappropriateness use of albumin. Methods: This was a retrospective medication use evaluation study conducting on 50 randomly selected patients prescribed and administered at least one dose of albumin. Inclusion criteria were adult patients and the exclusion criteria were pediatric and neonate. Results: There were eight cases out of 50 (16%) patients where albumin was prescribed inappropriately according to the guideline recommendations and this was an unnecessary expense for them, and a higher percentage (17 out of 50 patients, 34%) where the physician does not clarify why did he prescribed albumin. Two patients (4%) received the inappropriate dose, and only one patient (2%) received the inappropriate concentration of albumin, all the eight cases with inappropriate albumin indication were with albumin 20%, and the total cost of inappropriate albumin indication was 1800 SR for all the patients. Conclusion: The results demonstrated a high rate of inappropriate albumin prescribing which results in unnecessary cost. Moreover, in most of the cases, the physician does not clarify the indications of albumin, which make the judge of albumin appropriateness use, concentration, and dose difficult.


   Abstract SJG2020/11: The Utility of Digital Single-Operator Cholangioscopy in Biliary and Pancreatic Diseases: A Feasibility and Effectiveness Study at Two Tertiary Care Centers in Saudi Arabia (With Videos) Top


Abed Al Lehibi, Emad Aljahdali1, Areej Al Balkhi1, Thamer Almasoudi, Ahmad Al Ghamdi, Khalid Al Sayari, Abdullah AlKhathlan, Adel Qutub2, Nawwaf Al Otaibi, Ahmad AlEid, Shameem Ahmad, Abdullah Al Mtawa

Departments of Gastroenterology and 2Hepatology, King Fahad Medical City, Riyadh, 1Department of Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia

E-mail: [email protected]

Background: Since its inception in 2007, many studies have been published to evaluate the feasibility, usefulness, cost-effectiveness, and safety profile of the first-generation single-operator cholangioscopy (SOC). This paper is a descriptive study in which we share the experience of two tertiary care centers with the novel version of SOC, SpyGlass DS. Methods: We retrospectively reviewed the records of all the patients who went through the procedure from October 2015 to July 2019 to explore the scope of biliary and pancreatic conditions in which SOC was utilized. Technical success was defined by the ability to visualize the lesion and complete the procedure as planned, whereas clinical success was determined by the ability to achieve the desired diagnostic/therapeutic outcome. Results: Sixty-six patients (34 males) went through 84 procedures [Table 1]. Forty-four patients failed conventional extraction methods and required the intervention to treat difficult stones, 24 patients needed a diagnostic evaluation of biliary strictures, and three needed an intervention to remove migrated stents. Technical success was achieved in 98.8% (83/84) of the procedures (95% confidence interval [CI]: 96%–100%). Regarding clinical success, stone breakdown and removal were achieved in 92% of the procedures (49/53; 95% CI: 85%–100%). Tissue samples were successfully obtained in 95.8% (23/24) of the patients with strictures (95% CI: 88%–100%). The biopsy was appropriate to make a histological diagnosis in 83.3% of the cases (20/24; 95% CI: 68%–98%). The median number of sessions needed to achieve the desired outcome was one (ranging between 1 and 6 sessions). Conclusion: The digital version of SOC provides a feasible and an effective option for managing difficult cholelithiasis, as well as visually evaluating and obtaining histological samples for indeterminate biliary strictures.
Table 1: Number and types of single-operator cholangioscopy by SpyGlass DS

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   Abstract SJG2020/12: Removal of Proximally Migrated Biliary Stents Using Single-Operator CholangioscopY: A Video Case SerieS Top


Abed Al Lehibi, Abdullah Al Mtawa1, Thamer Almasoudi1, Adel Al Ghamdi1, Nawwaf Al Otaibi1, Areej Al Balkhi

Departments of Gastroenterology and 1Hepatology, King Fahad Medical City, Riyadh, Saudi Arabia

E-mail: [email protected]

Background: Migration is one of the late complications of biliary stenting. It occurs in 1%–20% of cases and is associated with a diverse array of adverse events. In this paper, we report our take-on endoscopic extraction of the proximally migrated biliary stents using single-operator cholangioscopy. Methods: This report includes three patients who were found to have proximal stent migration while being treated for biliary stones. One patient had a migrated metal stent, while the other two had plastic ones. Single-operator cholangioscopy (Boston Scientific SpyGlass™ DS) was used to retrieve the stents in all patients. The SpyBite™ biopsy forceps accessory was used to extract the metal stent, whereas the SpyBasket and the SpySnare were used to extract the plastic ones. Results: All patients ended up with a successful stent removal with the techniques described in this report with no immediate adverse events and completed more than 4 weeks of follow-up with no further complications. Conclusions: Digital single-operator cholangioscopy with SpyBasket, and retrieval snare, and SpyBite™ biopsy forceps can be the useful tools to remove migrated plastic and metallic stents, respectively.


   Abstract SJG2020/13: Clinical Picture of Celiac Disease: Experience of a Single Healthcare Provider in Saudi Arabia Top


Diamond Joy, Fuad Y. Maufa, Nassir A. Al Hayaf, Carole A. Merriwether

Department of Gastroenterology, Johns Hopkins Aramco Hospital, Dhahran, Saudi Arabia

E-mail: [email protected]

Background: Celiac disease has well described clinical features. Most studies describing clinical features and associations of celiac disease come from the studies conducted in the western world. Our aim was to determine the clinical features and associations of celiac disease from our center serving a Middle East population in Saudi Arabia. Methods: This retrospective study was conducted at a single center with catchment population of 158,000 patients. All patients with biopsy-confirmed celiac disease receiving health care at a center in the eastern province in Saudi Arabia between April 2002 and December 2018 were identified. Individual case records were reviewed. In addition, the Slicer Dicer function was also used from the electronic medical health record (EPIC) for analyzing the clinical features and associations. Results: Celiac disease was confirmed in 149 patients of which 66% were female. There was progressively increased yield of confirmed celiac disease over the study period. This was paralleled by an increase in TTG antibody tests performed year by year. Only 77 (51.6%) patients had gastrointestinal symptoms. 26% of the patients had iron deficiency anemia. 24 patients (16%) had diabetes, of which 46% were type 2. 18 (12%) patients had osteoporosis or osteopenia, and 28 (19%) had various skin diseases. Conclusion: In Saudi Arabia, celiac disease is being increasingly recognized, largely because of increased awareness and increasing TTG antibody testing. Many patients present with nongastrointestinal symptoms. Knowledge about the varied clinical features and the targeted use of celiac serology should lead to even earlier recognition of the disease.


   Abstract SJG2020/14: The Epidemiology and Clinical Characteristics of Portal Vein Thrombosis at King Fahad Hospital of The University: A Case–Control Study Top


Zahra A. Al Saeed1, Fatima A. Abusrir1, Fatima M. Alabdrabalnabi1, Fatima L. Alkhabbaz1, Hind Alsaif 2, Mona H Ismail1,3

1College of Medicine, Imam Abdulrahman Bin Faisal University, King Fahad Hospital of the University, 2Department of Radiology, King Fahad Hospital of the University, 3Department of Medicine, Gastroenterology Unit, King Fahad Hospital of the University, Khobar, Saudi Arabia

E-mail: [email protected]

Background: Portal vein thrombosis (PVT) is an uncommon, yet frequently encountered condition in clinical practice. Epidemiological data on PVT in Saudi Arabia are insufficient to guide clinical practice. The aim of our study is to determine the epidemiology and clinical characteristics of PVT in cirrhotic and noncirrhotic patients presenting at King Fahad Hospital of the University (KFHU), Saudi Arabia. Methods: This is a retrospective case–control study of all patients diagnosed with PVT based on Doppler ultrasonography attending at KFHU between January 2000 and January 2019. We identify 142 patients, of which 71 conformed diagnosis of PVT. 71 controls were identified by randomized computerized analysis during the same study period. Clinical, laboratory, and radiological findings were reviewed. Analysis was conducted using SPSS. P < 0.05 was considered statistically significant. Results: The mean age of diagnosis of PVT was 45.5 years. The male-to-female ratios for PVT group and control group were 1.7:1 and 1.2:1, respectively. The percentage of the patients with liver cirrhosis with PVT was 53.5%. Hypercoagulability and hepatocellular carcinoma were also found to be the risk factors for PVT. The clinical presentations of PVT were variable, but most patients presented with abdominal pain (36.6%), local factors (33.8%), and decompensated liver cirrhosis (15.5%). Cirrhosis and prolong prothrombin time (PT) were the predictors of developing PVT by 2.14 and 2.12, respectively, on univariant logistic regression. Conclusion: The clinical characteristics of PVT are variable, and most patients present with abdominal pain. Cirrhosis and PT were the significant predictor factors for the development of PVT.


   Abstract SJG2020/15: Accuracy of Triple Echo Magnetic Resonance Imaging in Predicting Hepatic Steatosis in Potential Liver Living Donors Top


Mohammed Aljawad, Rehab Abdulla, Mohammed Alqahtani, Miral Mashhour1, Zainab Alawami2, Suha Albadr2

Liver Transplant Department, Multi-Organ Transplant Unit, King Fahad Specialist Hospital, 1Department of Pathology, King Fahad Specialist Hospital, 2Medical Body Imaging Department, King Fahad Specialist Hospital, Dammam, Saudi Arabia

E-mail: [email protected]

Background: Living donor liver transplantation is a lifesaving procedure for patients with end-stage liver disease, especially in regions where there is severe shortage in cadaveric liver grafts. Hepatic steatosis >10%–15% is considered a limitation for donation in many centers. The goal of this study is to evaluate the accuracy of triple echo magnetic resonance imaging (MRI) to predict hepatic steatosis in potential liver donors in comparison to liver histopathology. Methods: This was a single-center, retrospective study including potential liver donors who underwent triple echo MRI of the liver and liver biopsy between March 2015 and November 2019. Liver fat fraction was measured by triple echo MRI as part of the donor evaluation process and compared to liver biopsy. Sensitivity and specificity of fat fraction by triple echo MRI were calculated. Correlation between MR fat fraction and histopathology evaluation was examined by Pearson's correlation coefficient. Results: In the study period, 35 potential liver donors with both triple echo MRI and liver biopsy were included. The correlation coefficient of triple echo MRI and histopathological hepatic steatosis was r of 0.860. For threshold of =10% steatosis, triple echo MR demonstrated sensitivity of 71.43%, specificity 92.86%, positive predictive value 71.43%, and negative predictive value 92.86%. Conclusion: There is a good correlation between triple echo MR fat quantification and histopathological steatosis with good performance to exclude significant hepatic steatosis =10%. Triple echo MR might be enough for evaluating hepatic steatosis in potential liver donors.


   Abstract SJG2020/17: Are Patients with Nonalcoholic Fatty Liver Disease at Risk of Endothelial Dysfunction? Top


Waleed Al-Hamoudi1,2, Amani Alsadoon2, Mazen Hassanian2,3, Hisham Alkhalidi4, Ayman Abdo1,2, Mohamed Nour5, Rabea Halwani6, Faisal M. Sanai7, Abdulsalam Alsharaabi3, Khalid Alswat1,2, Ahmed Hersi5, Ali Albenmousa8, Faisal Alsaif2,3

Departments of 1Medicine, 3Surgery, 4Pathology and 5Cardiac Science, College of Medicine, King Saud University, 2Liver Research Center, King Saud University, 6Immunology Research Laboratory and Asthma Research Chair, College of Medicine, King Saud University, 7Department of Medicine, Gastroenterology Unit, King Abdulaziz Medical City, Jeddah, 8Department of Liver Transplantation and Hepatobiliary Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia

E-mail: [email protected]

Background: Nonalcoholic fatty liver disease (NAFLD) is one of the most common liver diseases encountered worldwide. The relationship between NAFLD and cardiovascular disease has grown significantly in the past few years. We aimed to assess endothelial function through the evaluation of flow-mediated dilatation (FMD) of the brachial artery. Methods: Patients were recruited at the time of admission for laparoscopic cholecystectomy. Clinical, laboratory, and histological data were collected prospectively from the study population. Endothelial function was assessed through the evaluation of FMD of the brachial artery. Results: A total of 139 patients were included in this prospective study (50 healthy controls, 47 NAFLD patients with steatosis, and 42 NAFLD patients with steatohepatitis). All included individuals were nondiabetic (HBA1C <6.4); furthermore, patients with long-standing hypertension or uncontrolled blood pressure, smokers, and morbidly obese (body mass index > 40) patients were excluded. The median (ranges) for vascular FMD in the nonalcoholic steatohepatitis, steatosis, and control groups was 6% (0%–37.5%), 10.8% (0%–40%), and 13.6% (0%–50%), respectively. Control patients had a higher average FMD compared to patients with NAFLD (15.13 vs. 10.46%); this difference reached statistical significance when comparing the control and steatohepatitis groups (13.6 vs. 6, P = 0.027). Alanine aminotransferase was significantly higher in the steatohepatitis group compared to the steatosis and control groups (54 vs. 31, P = 0.008). Cholesterol levels were similar in all groups. Conclusion: In the absence of major cardiac risk factors, we demonstrated a better endothelial function in healthy controls, manifested by a higher FMD of the brachial artery compared to NAFLD patients.


   Abstract SJG2020/18: Prevalence of Biopsy-Proven Nonalcoholic Fatty Liver Among Patients with Gallstone Disease Top


Sara H. Qahtani, Amani M. Alsadoon1, Ayman A. Abdo1, Mazen M. Hassainan, Abdulsalam B. Alsharabi, Ghadeer R. Aljuhani, Hisham M. S. Alkhalidi2, Mohammad S. Elsharkawy3, Maram A. Alotaibi2, Waleed K. Al-Hamoudi1,4, Faisal A. Alsaif

Department of Surgery, College of Medicine, King Saud University, 1Liver Disease Research Center, King Saud University Medical City, 2Department of Pathology, College of Medicine, 3Department of Radiology and Medical Imaging, King Saud University Medical City, 4Department of Liver Transplant, King Faisal Specialist and Research Hospital, Riyadh, Saudi Arabia

E-mail: [email protected]

Background: Gallstone disease (GD) and nonalcoholic fatty liver disease (NAFLD) are associated with metabolic syndrome. Despite the benign nature of NAFLD, 10% of patients may develop advanced fibrosis and cirrhosis. We aimed to identify the prevalence and factors associated with NAFLD among GD patients in the Saudi population. Methods: This is a single-center, observational cohort study that included patients seen in general surgery clinics at our institution from 2011 to 2017. All liver biopsies were taken at the time of cholecystectomy. Demographical and clinical data were prospectively collected from the study population. Results: A total of 301 GD patients were included in this study. The percentage of patients who were normal, overweight, and obese was 15%, 29%, and 56%, respectively. 47.8% (143) of patients had NAFLD, of which 41.8% (125) showed steatosis, and 6% (18) had nonalcoholic steatohepatitis. A significant positive correlation between age and body mass index (BMI) and NAFLD was found. Obese patients with a BMI of 30–34.9 were 3.833 (P = 0.028) times more likely to have NAFLD compared to patients with normal BMI, and this value increased to 7.872 (P = 0.019) in patients with BMI exceeding 40. In addition, patients with diabetes were 4.114 times (P = 0.034) more likely to have NAFLD compared with those who did not. Conclusions: The prevalence of NAFLD among GD patients is high. High BMI and diabetes are the independent factors associated with NAFLD in GD patients. This study would be useful in proposing the need for routine liver biopsy in selected patients during cholecystectomy.


   Abstract SJG2020/19: Validating Candidate Biomarkers for Different Stages of Nonalcoholic Fatty Liver Disease Top


Reem Al-Qarni, Mohammed Iqbal, Maram Al-Otaibi1, Faisal Al-Saif2,3, Assim Al-Fadda4, Hisham Alkhaldi1, Fahad Bamehriz2, Mazen Hassanain2,3,5

Department of Physiology, 1Pathology and 2Surgery, College of Medicine, King Saud University, 4Obesity Research Center, King Saud University, Riyadh, 5Liver Disease Research Center, King Saud University, Riyadh, Saudi Arabia, 3Department of Oncology, McGill University, Montreal, Quebec, Canada

E-mail: [email protected]

Background: Nonalcoholic fatty liver disease (NAFLD) is a common chronic condition caused by the accumulation of fat in the liver. NAFLD may range from simple steatosis to advanced cirrhosis and affects more than one billion people around the world. To date, there has been no effective treatment for NAFLD. In this study, we evaluated the expression of four candidate NAFLD biomarkers to assess their possible applicability in the classification and treatment of the disease. Methods: Twenty-six obese subjects were recruited and their liver biopsies were obtained. Expression of four candidate biomarker genes, PNPLA3, COL1A1, PPP1R3B, and KLF6, were evaluated at gene and protein levels by RT-qPCR and ELISA, respectively. Results: A significant increase in the levels of COL1A1 protein (P = 0.03) and PNPLA3 protein (P = 0.03) was observed in patients with fibrosis stage compared to that in patients with steatosis stage. However, no significant differences were found in abundance of PPP1R3B and KLF6 proteins or at the gene level for any of the candidate. Conclusion: This is the first study, to our knowledge, to report on the expression levels of candidate biomarker genes for NAFLD in the Saudi population. Although PNPLA3 and PPP1R3B had been previously suggested as biomarkers for steatosis and KLF6 as a possible marker for the fibrosis stage of NAFLD, our results did not support these findings. In addition, our results support COL1A1 protein as a potential biomarker for the fibrosis stage of NAFLD. Further studies are required to validate the use of COL1A1 as a biomarker for advanced NAFLD in a larger cohort.


   Abstract SJG2020/20: Long-Term Outcome of Patients Transplanted for Nonalcoholic Steatohepatitis-Related Cirrhosis Top


Isam Salih1, Sarra Yousif1, Khalid Bzeizi1, Saad Alghamdi1, Ali Albenmousa1, Saleh Alqahtani1, Waleed Al-Hamoudi1,2

1Department of Liver Transplantation and Hepatobiliary Surgery, King Faisal Specialist Hospital and Research Center, 2Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia

E-mail: [email protected]

Background: Cirrhosis secondary to nonalcoholic steatohepatitis (NASH) is projected to become the leading indication for liver transplantation (LT) worldwide. We aimed to evaluate the prevalence of metabolic syndrome and long-term outcome of patients transplanted for NASH-related cirrhosis. Methods: All patients transplanted for NASH-related cirrhosis at our institution from 2001 to 2016 were included in this study. Patients' data were collected from our prospectively collected database. Results: A total of 108 patients were transplanted for NASH-related cirrhosis at our institution. Sixteen (15%) patients had pretransplant hepatocellular carcinoma. Pretransplant obesity (body mass index > 30), diabetes, hyperlipidemia, and hypertension were present in 43 (40%), 57 (53%), 20 (19%), and 30 (28%) patients, respectively. Following LT patients were followed for an average of 103 months (range 54–203 months). Posttransplant diabetes, hyperlipidemia, and hypertension were present in 62 (57%), 25 (23%) and 48 (44%) patients, respectively. Fifty (46%) patients developed disease recurrence with significant fatty infiltration on various imaging modalities. Further, 48 (44%) patients developed renal impairment (GFR <60). Sixteen patients were treated for mild rejection and only one patient developed ductopenic rejection resulting in graft loss. Sixteen (15%) patients developed severe cardiovascular complications. Overall survival during the follow-up period was 83%. One-year and 3-year survivals were 92.5% and 87%, respectively. Sepsis was the most common cause of death in our patient population. Three patients died secondary to acute cardiovascular events. Conclusion: Disease recurrence in our patient population was common; however, posttransplant cirrhosis remains rare. The prevalent metabolic syndrome negatively impacted renal function and resulted in cardiovascular complications.


   Abstract SJG2020/21: Efficacy of Radiofrequency Ablation in the Treatment of Patients with Hepatocellular Carcinoma and Compensated Liver Disease: A Pathological Evaluation of Liver Explants Top


Waleed Al-Hamoudi1,2, Issam Salih2, Sarra Yousif2, Khalid Bzeizi2, Saleh Alqahtani2, Ali Benmousa2, Mark Sturdevant2, Dieter Broering2, Hamad Alsuhaibani3

Departments of 1Liver Transplantation and Hepatobiliary Surgery and 3Radiology, King Faisal Specialist Hospital and Research Center, 2Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia.

E-mail: [email protected]

Background: Radiofrequency ablation (RFA) is a safe and effective treatment for patients with limited hepatocellular carcinoma (HCC). We aimed to correlate the radiological tumor response of RFA with the histopathologic examination of explanted livers following liver transplantation (LT). Methods: All compensated patients treated with RFA before LT at our institution from 2007 to 2018 were included in this study. Patients' data were collected from our prospectively collected database. Results: A total of 29 patients were treated with RFA before LT. 12 (41%), 12 (41%), and 5 (18%) patients had a single, two, or three lesions, respectively. 17 (58.6%), 8 (27.6%), 3 (10.3%), and 1 (3.4%) received 1, 2, 3, and 4 sessions, respectively. When comparing RFA for single or multiple HCC with no lesion more than 3 cm, pathological cure was significantly higher, 85% (12/14) of cases versus 46% (7/15) in patients with lesions exceeding 3 cm (P = 0.027). Pathological cure was 100% (4/4) in patients with a single lesion less than 3 cm. Furthermore, six patients had lesions on the explant examination that were not demonstrated on the pretransplant imaging. Two patients developed new lesions on follow-up imaging before LT. None of the included patients developed posttransplant HCC recurrence during the post-LT follow-up period (54 months, range 1–131 months) and the overall survival was 76%. Conclusion: The HCC histopathologic characteristics in the explanted liver at the time of LT have a dual function in both reflecting the efficacy of preoperative locoregional therapy and as a predictive factor for HCC recurrence.


   Abstract SJG2020/22: Going Outside Milan and within San Francisco Criteria Does not Increase Recurrence Rate of Hepatocellular Carcinoma Postliver Transplant Top


Elwy Soliman, Sarra Yousif, Mohamed Shawkat, Isam Salih, Ali Albenmousa, Waleed Alhamoudi, Khalid Bzeizi, Saleh Alabbad, Roberto Troisi, Dieter Broering

Organ Transplant Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

E-mail: [email protected]

Background: Liver transplantation (LT) for hepatocellular carcinoma (HCC) is guided by several recognized criteria that aim for reducing recurrence risk. The aim of this study is to report the outcome of LT in a center that extends the criteria of transplantation beyond Milan Criteria and within San Francisco (SF) criteria. Methods: A retrospective study was carried out on patients who underwent LT for HCC at King Faisal Specialist Hospital and Research Centre, Saudi Arabia, between June 2001 and March 2018. Patients were included if their tumor was within SF criteria and were divided into within Milan (WM) and outside Milan (OM) groups. Results: One hundred and eighty-two patients were included in the study. Those in WM criteria were 134 (73.6%) and patients in OM criteria were 48(26.4). After a median follow-up of 45.4 months (0–210 months), the overall mortality of this cohort was 21.3%; however, 14 patients (7.7%) had early death (within 3 months after LT) and the cause of death was unrelated to recurrence of HCC. Recurrence of HCC was diagnosed in 11 patients (6%) of the whole cohort, and 6.5% of patients who survived >3 months. The recurrence rate did not differ between WM (7/134) and OM (4/48) groups (5.2 vs. 8.3% P = 0.484). The median time to recurrence was 8.3 months (4–29 months). Recurrent HCC was the cause of death in nine patients while two patients lost to follow-up. Conclusions: Extending the selection criteria beyond Milan and within SF criteria did not adversely affect the transplant outcome, particularly with regard to HCC recurrence.


   Abstract SJG2020/23: Long-Term Virologic Response in Patients with Chronic Hepatitis B Virus After Entecavir Therapy Top


Sara H. AlQahtani1,2, Rana A. AlJunaidel2, Maram A. Alaqel2, Abdullah Alkhathlan2, Awny Ali2, Ayman Abdo2, Waleed Al-Hamoudi2, Khalid Alswat2, Faisal Alsaif2, Weam Hussein2, Maram Alkhammash2, Esther Robles2, Mazen Hassanain2

1College of Medicine, King Saud University, 2Liver Disease Research Center, King Saud University Medical City, Riyadh, Saudi Arabia

E-mail: [email protected]

Background: Hepatitis B virus (HBV) is known as a major leading factor for cirrhosis, hepatocellular carcinoma, and liver failure. Pegylated interferon, entecavir, and tenofovir are approved as the first-line therapy; entecavir has been effective and well tolerated; however, due to the scarcity of studies regarding the long-term response of entecavir in HBV patients in our region, we aimed to identify the virologic and biochemical response in chronic HBV patients treated with entecavir. Methods: A retrospective cohort study conducted at KSUMC. All chronic patients treated with entecavir and confirmed as hepatitis B surface antigen (HBsAg)-positive for at least 6 months were recruited. Patients with a history of HCV or HIV co-infection, interferon treatment, prior diagnosis of HCC, and being <18 years old were excluded. To identify 10 years' efficacy, we have studied HBsAg (qHBsAg) and HBe antigen (HBeAg) levels, viral load, ALT, and AST. Results: A total of 197 patients were treated and followed up for 10 years; readings were based on their visits in the 1st, 5th, and 10th year. Results showed a rise in HBsAg to 100% in the 10th year. qHBeAg decreased to 16.4% in the 5th year and raised again to 27.8% at 10 years (P = 0.002). Viral load decreased significantly from 417,004 to 20 IU/mL (P = 0.014). Biochemical response of ALT and AST had a median of 66.50 and 33 at baseline and their lowest levels were in 10 years with a median of 31 and 21, respectively. Conclusion: Chronic HBV patients showed a significant excellent virologic and biochemical response to long-term entecavir treatment.


   Abstract SJG2020/24: Reactivation of Hepatitis B Virus Following Kidney Transplantation In Hepatitis B Surface Antigen-Negative/Anti-Hepatitis B Core-Positive Patients Top


Mohammed Aljawad, Khaled Saleh, Mohammed Alqahtani, Khalid Akkari, Mohammed Soliman, Fayaz Handoo, Ali AlShaqaq

Multi-Organ Transplant Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia

E-mail: [email protected]

Background: Patients with end-stage kidney disease have more prevalence of hepatitis B virus (HBV) exposure than general population. Hepatitis B reactivation is well documented in patients with HBV infection after receiving immunosuppressive medications. Although the risk of HBV reactivation is less in patients with prior (resolved) infection, there is a considerable risk in patients receiving heavy immunosuppression such as rituximab or bone marrow transplantation with detrimental consequences. The rate of HBV reactivation postkidney transplantation is not well described in patients with history of resolved infection. Methods: A retrospective chart review of adult patients who received ?kidney transplantation at King Fahad Specialist Hospital-Dammam between January 2009 and December 2018 with evidence ?of resolved HBV infection (hepatitis B surface antigen [HBsAg] negative, anti-hepatitis B core positive, anti-HBs positive or negative, and normal liver enzymes). ?HBV reactivation was defined as HBsAg seroconversion from negative to positive and/or HBV DNA >2000 IU/mL. Results: A total of 1128 patients received kidney transplantation during the study period. A total of 112 (9.9%) patients have evidence of resolved HBV infection. Mean age was 57.8 years and 66% were males. 91% (n = 102) were on dialysis and 8% had a history of prior transplant. Immunity against HBV was identified in 59.8% of the patients with negative HBV DNA in all patients. 81% received living kidney transplant and anti-thymocyte globulin was the induction agent in 82% of the patients. ?HBV prophylaxis was given for 12 patients. Patients and graft survival were 97% at 1 year. HBV reactivation developed in 2.7% (n = 3) patients with mean time of 23 months post transplantation. One patient received HBV prophylaxis before reactivation, two lost their anti-HBs antibody, and one has evidence of elevated liver enzymes at time of reactivation. Conclusion: Hepatitis B reactivation is not negligible postkidney transplantation in patients with resolved infection. We suggest routine frequent monitoring of patients with resolved infection postrenal transplantation with liver enzymes and HBV serology with or without HBV DNA as well as vaccination pre- and post-transplant.


   Abstract SJG2020/25: A Regional Survey of Awareness of Inflammatory Bowel Disease in the Western Region of Saudi Arabia Top


Yaser Meeralam, Mahmoud Mosli1, Adnan Zanbagi, Yousef Qari1, Mona Al Saedi, Ahmad Afghani2, Abulwahab Neyazi, Ghadeer Al Hazmi, Faisal Batwa3, Mohammad Sharif

Division of Gastroenterology, Digestive and Liver Health Center, King Abdullah Medical City, Makkah, 1Department of Internal Medicine, Division of Gastroenterology, King Abdulaziz University, 3Department of Medicine, Gastroenterology Unit, King Abdulaziz Medical City, Jeddah, 2Department of Medicine, Al Madinah General Hospital, Madinah, Saudi Arabia

E-mail: [email protected]

Background: Inflammatory bowel disease (IBD) is a chronic disease broadly classified into Crohn's Disease (CD) and ulcerative colitis (UC). Its surging incidence globally will burden healthcare systems across the world. Diagnostic delay is common, leading to preventable complications and poor response to therapy. Lack of awareness of IBD may accentuate the delay. Hence, the aim was to understand the awareness of CD/UC among the general population of Kingdom of Saudi Arabia. Methods: A questionnaire developed based on the previous study, translated into Arabic according to WHO criteria, and reviewed by IBD experts was administered to the public aged above 16, through awareness programs, hospitals, community places, and internet-based survey. Results: A total of 640 participants completed the questionnaire with 65% having a qualification of bachelors and above. 43% and 32% had never heard or did not know about, 46% and 51% had heard or read about, and 11% and 16% had personal contact will CD and UC, respectively. When asked about cure for CD and UC, 31% and 39% said that it was curative; 16% and 15% said that it was not curative; and 53% and 46% were not sure, respectively. 36% and 19% did not know which organ was affected by CD and UC, respectively. Intestine as the affected organ for CD and UC was selected by 53% and 79% of respondents. Liver, heart, and head were the other choices selected by 1%–2% for both CD and UC. Conclusion: Despite high level of education in our cohort, more than one-third were lacking in IBD knowledge. There is a need to increase public awareness of IBD.


   Abstract SJG2020/26: CLinical Outcomes of Stricturing Ileal Crohn'S Disease Treated with Anti-Tumor Necrosis Factor Therapy: A Retrospective Analysis Top


Mansour Alourfi, Mahmoud Mosli

Department of Medicine, Gastroenterology Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia

E-mail: [email protected]

Background: Little is known about the efficacy and safety of anti-tumor necrosis factor (TNF) therapy in patients with intestinal strictures due to Crohn's disease (CD). We aimed to determine whether anti-TNF therapy can help avoid or delay surgery in ?patients with CD presenting with a symptomatic stricture of the small bowel. Methods: We retrospectively evaluated the clinical course of 75 patients with CD and small bowel strictures registered in the King Abdulaziz University Hospital inflammatory bowel disease information system registry. Patients treated with at least 12 weeks of anti-TNF therapy (adalimumab or infliximab) were considered in the treatment arm; otherwise, the remaining patients were considered in the nontreatment (comparator) arm. Patients with nonresolving complete bowel obstruction at baseline were excluded. The primary outcome was to compare the proportion of patients requiring endoscopic balloon dilatations and surgical resection between the two groups. The secondary outcome was to compare time to surgical resection in months. Results: Surgical resection was required for 7/75 (9.3%) patients; 6/50 (12.2%) treated with biologics versus 1/25 (4%) not treated with biologics, P = 0.26. Endoscopic dilatation was required for 2/50 (4%) patients treated with biologics versus 1/25 (4%) patients not treated with biologics (P = 0.69). No statistically significant difference was observed between time to surgical resection between the two groups (hazard ratio = 76.27, 95% confidence interval = 0.002–127762.1, P = 0.54). Conclusions: Our results suggest that treating patients with stricturing small bowel CD with anti-TNF provides no additional advantage with regard to the need for surgical intervention.


   Abstract SJG2020/27: Preliminary Results of the Use of Inflammatory Bowel Disease Disk in Outpatients Top


Adnan AlZanbagi, Yaser Meeralam, Abdulaziz Tashkandi, Saad AlZahrani, Mohamad Khan, Salem Alotaibi, Ahmed Laeeque, Inayatullah Sharif Mohamad Khilji

Gastroenterology Division, Digestive and Liver Health Center, King Abdullah Medical City, Makkah, Saudi Arabia

E-mail: [email protected]

Background: To assess disability in inflammatory bowel disease (IBD), a simple questionnaire-based tool called IBD disk has been developed. It has been prompted as a tool that can be used in routine clinical practice to capture IBD-related dysfunctions not otherwise discussed including abdominal pain, body image, education and work, emotions, energy, interpersonal interactions, joint pain, regulating defecation, sexual functions, and sleep. We aimed to study its use in real-world outpatient clinic. Methods: Patients with a confirmed diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) who attended the outpatient clinic were asked to fill in the Arabic version of IBD disk with the 10 questions, each scored on a scale from 0 to 10. In addition, clinical details of IBD were recorded. Preliminary results of this ongoing study are presented. Results: So far, 26 IBD patients (15 CD and 11 UC) with a mean age of 32 years and 62% (16) females completed the IBD disk. The mean score of each domain are shown in [Table 1]. Joint pain, energy, and body image scored the highest means of 2.81, 2.65, and 2.62, respectively. The lowest score was on sexual functions and work/education domains with a mean of 1.15 and 1.23, respectively. In patients with UC, the highest mean was scored for regulatory defecation and the lowest for education/work with scores of 2.73 and 1.00, respectively. However, in patients with CD, the highest mean was for body image and the lowest for sexual function with scores of 3.33 and 1.20, respectively [Table 1]. Conclusion: It was feasible to administer the IBD disk in outpatient setting. In the overall cohort joint, pain and energy were most disabling, whereas in UC and CD, regulating defecation and body image was most disabling, respectively.


   Abstract SJG2020/28: Clinical Presentation and Outcome of Primary Biliary Cholangitis: A Report from Tertiary Center In Saudi Arabia Top


Ali Albenmousa, Saad Alghamdi, Mohamed Shawkat, Esam Eldeen Salih, Elwy Soliman, Hazem M. Hasan, Badr A. Hemeda, Khalid Bzeizi, Waleed Al-Hamoudi, Dieter Broering

Organ Transplant Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

E-mail: [email protected]

Background and Aims: Primary biliary cholangitis (PBC) is a chronic liver disease of autoimmune origin that leads to chronic destruction of bile ducts with subsequent development of fibrosis and liver failure. The disease is more prevalent in the western world and the reports about its prevalence and clinical features in the Middle East are scarce. The aim of this study is to describe the clinical presentation and outcome of a cohort of PBC patients diagnosed in a single tertiary center in Saudi Arabia. Patients and Methods: This is a retrospective descriptive cohort study conducted at King Faisal Specialist Hospital and Research Center. All patients diagnosed as PBC (based on positive antimitochondrial antibody [AMA], biochemical evidence of cholestasis, and exclusion of other causes of chronic liver disease except those with viral hepatitis and histological features of PBC with positive AMA) included in the analysis. Demographic, biochemical, serological, and histological data were collected and analyzed descriptively and inferentially using SPSS version 18. Results: from January 2008 till December 2018, 116 patients were diagnosed as PBC. The mean age was 50.5 ± 12.6 years and 86.2% were females. At presentation, 54.3% of the patients had clinical or radiological evidence of cirrhosis and 15.5% of them required liver transplantation, while the overall mortality was 14.7%. Hepatocellular carcinoma complicated cirrhosis in four cases (3.5%). Autoimmune hepatitis was overlapping with PBC in 39% of the cohort. Besides positive AMA, 77% of the patients had positive ANA (=1/80), 29.5% had positive ASMA, and 3% had positive LKM. The probability of death or liver transplantation was higher in cirrhotics (P = 0.000) and in patients with hyperbilirubinemia (P = 0.000) and low platelets (P = 0.000). of the 85 patients treated with ursodeoxycholic acid, 71% achieved biochemical response (ALP <1.67 times the upper limit of normal). Conclusion: Primary biliary cholangitis is not uncommon disease in our region, and it can lead to significant liver-related morbidity and mortality. Screening of patient with chronic liver disease for PBC is required for earlier recognition and initiation of treatment.
Table 1: Mean score of each domain in the IBD patients

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   Abstract SJG2020/29: Physician Attitude and Knowledge Toward Colorectal Cancer Screening in Primary Healthcare Centers in Qassim, Saudi Arabia Top


Feras Aljemeeli, Abdulrahman AlFadda

Department of Medicine, Gastroenterology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

E-mail: [email protected]

Background: Incidence of colorectal cancer (CRC) is ranked first most common carcinoma for males and the second most common cancer for females. CRC is an ideal for prevention because of the high incidence and the relatively slow progression into an adenocarcinoma. Primary health care (PHC) setting is the ideal place where CRC screening should take place. Methods: A cross-sectional study was performed among PHC physicians in Qassim Province, Saudi Arabia. A comprehensive electronic questionnaire adopted from the national cancer institute was formulated. Demographic data, specialty, qualifications, years of experience, knowledge and attitudes toward CRC screening, and perceived barriers regarding CRC screening were obtained. Results: A total of 95 physicians were recruited. 94.7% of the physicians work in PHC center. 69.1% from physicians were classified as residents, 28% are Registrars, and 3.2% are consultants. 99% of the physicians agree that CRC screening is needed when age appropriate. However, 68% were very compliant in CRC screening in clinical practice. 78% of the physicians reported unavailability of fecal occult blood testing tools in their clinic. Only 52% of the physicians were familiar with national CRC cancer screening guidelines. 53% of the physicians scored correct on the age appropriate to initiate CRC screening for average risk patients. 51% of the physicians were correct on how many samples required for adequate fecal occult blood test while 58% of the physicians were familiar on required aforementioned test instructions. Conclusions: More efforts, funding, and planning are required in the targeted area to make CRC prevention more efficient.


   Abstract SJG2020/30: Longitudinal Assessment of Hepatic Fibrosis in Chronic Hepatitis C Responders to Direct-Acting Antivirals Top


Khalid Alswat1,2, Waleed Al-Hamoudi1,2, Ayman A. Abdo1,2, Abdullah Alkhathlan1,2

1Department of Medicine, College of Medicine, King Saud University, 2Liver Disease Research Center, King Saud University, Riyadh, Saudi Arabia

E-mail: [email protected]

Background: Accumulating evidence has shown that viral elimination can lead to improvement in clinical, histologic, and biochemical outcomes and reduce overall mortality and risk of death from liver-related and nonliver-related causes. Regression of fibrosis when patients achieve sustained virologic response (SVR) with interferon-based (INF-based) therapy is well documented, albeit slowly and not uniformly in all patients. In the direct-acting antivirals (DAAs) era, studies of fibrosis changes post-SVR are limited. Methods: This is the interim analysis of the study of prospective follow-up evaluation of the fibrosis parameters' changes in hepatitis C virus (HCV) responders to DAA therapy. Results: So far, 130 HCV responders have completed follow-up assessment and were included in this analysis, with a mean age of 54.5 ± 14.2 years, 45.5% being male, 33% having prior HCV treatment experience along with a follow-up of 145.9 ± 54.4 weeks. Patients were classified based on baseline fibrosis status into 35% low and 75% significant fibrosis, out of this 30% had baseline cirrhosis. When compared with baseline parameters, significant improvement has been observed in ALT, AST, ALP, albumin, and platelets. LSM improved from 145.9 ± 54.4 to 9.34 ± 6.91 (P < 0.001). Similarly, significant posttreatment improvement was observed in AST-to-platelet ratio index, fibrosis-4 scores, and AST/ALT ratio. These findings are consistent in the analysis in the whole group and fibrosis subgroups. Conclusions: Treatment of HCV with achievement of SVR is associated with significant laboratory parameters improvement including liver stiffness and noninvasive fibrosis serum markers' scores. Thus, monitoring of fibrosis is necessary, especially in patients with significant fibrosis at the time of SVR.


   Abstract SJG2020/31: Development of an Indigenous Regional Inflammatory Bowel Disease Registry Top


Adnan Al Zanbagi, Abdulaziz Tashkandi, Yaser Meeralm, Mohammed Khan, Maher Alhazmi, Elham Bugis, Zahid Bugis, M. K. Shariff

Division of Gastroenterology, Digestive and Liver Health Center, King Abdullah Medical City, Makkah, Saudi Arabia

E-mail: [email protected]

Background: Inflammatory bowel disease (IBD) is a chronic disease classified into Crohn's Disease (CD) and ulcerative colitis. The incidence of IBD is rising globally and is set to burden the healthcare across the world. To better understand the impact of IBD, real-world experience is essential. Establishment of a registry helps to characterize the disease phenotype, therapy outcome, and patient-reported measures. Methods: An indigenous registry for IBD was developed using Dendrite software in the Department of Gastroenterology of King Abdullah Medical City with the help of research department and software specialist. Based on the European Crohn's Colitis Organization guidelines, different parameters to capture IBD characteristics were incorporated into the IBD registry. The initial CD patients included so far were analyzed and presented below. Results: Fifty patients with CD analyzed had a mean age at diagnosis of 23 (standard deviation ± 10) years with 60% (30) male. 8% (4) reported a family history of CD and 4% (2) were smokers. CD was limited to ileum in 8% (4), involved just the colon in 20% (10), and both the ileum and colon in the remaining. Among the different medicines used, 52% (26) used 5-amino salicylic acid, 76% (38) were exposed to steroids, 82% (41) to immunomodulators, and 78% (39) to biologics. 34% (17) had some form of surgery for their disease. Conclusion: The initial experience of developing the local IBD registry has been promising with the ability to capture all important data and the simplicity of usage. There is on-going effort to collect more data and involve the regional hospitals.


   Abstract SJG2020/32: Laparoscopic-Assisted Endoscopic Retrograde Cholangiopancreatography After Gastric Bypass Surgery: A Retrospective Case Series Top


Abdul Monem Swied, Abdulrahman Aloun1, Ali Audah Alzahrani2, Fahad Alabeidi2

Department of Medicine and 2Surgery, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, 1Department of Medicine, Gastroenterology Division, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia

E-mail: [email protected]

Background: Accessing the biliary ducts for performing endoscopic retrograde cholangiopancreatography (ERCP) and relevant interventional procedures after gastric bypass surgery is technically difficult and unsuccessful due to anatomical alterations. To overcome such technical challenges, laparoscopic-assisted ERCP (LA-ERCP) is used to approach the biliary ducts via nonperoral reliable access for performing different endoscopic biliary interventions. Our objective of this study is to assess feasibility and performance of LA-ERCP. Methods: It was a retrospective case series of consecutive three patients undergoing LA-ERCP with different anatomic variations in a tertiary level hospital from 2015 to June 2019. Results: The LA-ERCP was performed in the following conditions: classic RYGB, minibypass after sleeve gastrectomy, and RYGB after biliopancreatic diversion. The average age was 35 years with male-to-female ratio of 2/1. The indication of ERCP was choledocholithiasis in the three patients. Two of them had a concomitant cholelithiasis that later underwent a cholecystectomy during admission. Sphincterotomy was performed in all patients. Biliary cannulation was successful in the three patients (100%). There were no endoscopic-related complications. Specifically, there were no cases of gastrointestinal bleeding, acute pancreatitis, or perforation. Moreover, there was not surgical complication. The average hospital stay was 2 days. Conclusion: Our institution's experience illustrates that LA-ERCP is a safe, successful, and useful approach as compared to conventional ERCP.


   Abstract SJG2020/33: The Yield of Surveillance Colonoscopy After Colorectal Cancer Resection Top


Abdulrahman Aloun, Majid Almadi

Department of Medicine, Gastroenterology Division, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia

E-mail: [email protected]

Background: Multiple surveillance strategies have been recommended for colorectal cancer (CRC) surveillance after resection, including colonoscopy, and additional sigmoidoscopy for a previous rectal cancer. However, there has been a debate about the optimal frequency of endoscopic surveillance and whether additional sigmoidoscopy is recommended or not among societies and expert groups. No previous study in our population assesses the yield of colonoscopy for such group of patients. The purpose of the study is to assess for a secondary CRC in our population in terms of timing, locations, and whether it is anastomotic recurrence or a recurrence at different site. Methods: In a retrospective study, we reviewed patients who underwent CRC resection and had subsequent colonoscopy surveillance follow-up from 2012 to 2019. It was conducted at King Khalid University Hospital, Kingdom of Saudi Arabia. Results: Among 149 patients who underwent CRC resection, 87 patients had follow-up surveillance colonoscopy at 1 year. Three patients developed CRC (3.44%), all of which represent anastomosis recurrence of rectal cancer. Sixty patients had subsequent surveillance colonoscopy done within 3–5 years. Two patients (3.33%) developed CRC, one of them had a recurrence at anastomosis of the previous rectal cancer, and the other had a different site of CRC. Conclusion: The yield of colonoscopy surveillance for CRC is high as compared to the other population. Rectal CRC recurrence accounts for the majority of cases. Hence, preforming additional sigmoidoscopy for a previous rectal cancer according to some society recommendations might change the outcome in our population. More data are needed for more accurate assessment.


   Abstract SJG2020/34: Validating Controlled Attenuation Parameter in Assessment of Hepatic Steatosis in Living Liver Donors Top


Mohamed Shawkat, Faisal Aba-Alkhail, Ahmad Jaafari, Waleed Alhamoudi, Roberto Troisi, Dieter Broering, Khalid Bzeizi

Department of Liver Transplantation and Hepatobiliary Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia

E-mail: [email protected]

Background: Hepatic steatosis assessment is essential for donor workup in living donor liver transplantation (LDLT). Liver biopsy is the gold standard, and despite its invasiveness, there is no consensus on alternative modalities. The controlled attenuation parameter (CAP) quantifies hepatic steatosis, and cumulative data are promising though little is known on its utility in LDLT donor workup. We aimed to assess the CAP in quantifying steatosis in donors undergoing workup for LDLT. Methods: A prospective study conducted in King Faisal Specialist Hospital (January 2018–September 2018). All consecutive potential living donors had FibroScan/CAP measurements and liver biopsy. The CAP cut-off values range is 180–350 dB/m and graded as S0 (=218), S1 (218–250), S2 (250–305), and S3 (>305 dB/m). Steatosis score by liver biopsy was S0 <5%, S1 (5%–33%), S2 (33%–66%), and S3 >66%. Results: One hundred liver donors were included and their scores were S0 (39 donors), S1 (20), S2 (26), and S3 (15). The liver biopsy score was S0 (72 donors), S1 (16), S2 (6), and S3 (6). CAP exhibited a significant ability to differentiate moderate-to-severe steatosis (area under the curve = 0.817, 95% confidence interval [CI]: 0.727–0.887, P < 0.001). A score of =2 is selected as the best cut-off value using Youden index. The sensitivity and specificity were 91.7% (95% CI: 61.7%–99.8%) and 65.9% (95% CI: 55.0%–75.7%). While a score of = 1 strongly excludes the presence of moderate–severe steatosis (negative predictive value = 98.3%, 95% CI: 89.8%–99.7%), a score of =2 was poor in confirming the presence of moderate–severe steatosis (positive predictive value = 65.9%; 95% CI: 55.0%–75.7%). Conclusion: CAP reliably identifies donors with no or mild steatosis. It is however not a good predictive test for moderate-to-severe steatosis. LDLT donors with a score >S1 should be considered for liver biopsy.


   Abstract SJG2020/35: Single Daily form of Tacrolimus Postliving Donor Liver Transplantation: Real-Life Experience Top


Mohamed Shawkat, Ali Albenmousa, Waleed Al-Hamoudi, Sarra Yousif, Aziza Alajlan, Roberto Troisi, Dieter Broering, Khalid Bzeizi

Department of Liver Transplantation and Hepatobiliary Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia

E-mail: [email protected]

Background: Nonadherence to immunosuppressive medications postliver transplant occurs in about 25% of patients. It contributes to about 20% of late acute rejection episodes and 16%–36% of graft losses. Moreover, it is a recognized contributing factor of rejection and graft loss. Number of drugs taken and frequent daily doses is a known contributing factor to noncompliance. Once-daily tacrolimus (TAC-QD) formulation could thus offer the potential benefit of improved medication compliance and possibly better allograft outcomes compared to the twice-daily tacrolimus (TAC-BID). We aimed to evaluate the safety and efficacy of conversion to once-daily, prolonged release tacrolimus in post-living donor liver transplantation (LDLT). Methods: This was a retrospective, single-center study conducted between June 2016 and September 2018. We selectively converted stable and long-term recipients of LDLT to TAC-QD based on tacrolimus trough level. All patients had no documented acute rejection at least 6 months before conversion. The tacrolimus dosage, trough level, liver and renal functions before conversion, and then 1, 3, 6, and 12 months after conversion were recorded. Results: Thirty-three liver transplant recipients received TAC-QD between June 2016 and September 2018. The mean age of the patients was 56.1 ± 13.1 years and two-third of the patients were males. The most frequently used dose was 1 mg (13 patients, 39.4%), 5 patients (15.2%) required less than 1 mg and 5 (15.2%) patients required more than 2 mg. After a median follow-up of 20 months, 21 patients (63.6%) have continued on TAC-QD with normal liver functions and no reported adverse events while 12 patients (36.4%) were converted back to TAC-BID after using it for 20–360 days. The reason for stopping TAC-QD was elevated liver enzymes which were normalized soon following conversion back the TAC-BID. Conclusions: TAC-QD is a good alternative to TAC-BID when patient compliance is a concern. Close monitoring of liver function tests however is essential to avoid significant graft rejection.


   Abstract SJG2020/37: Two Saudi Brothers with Familial Visceral Myopathy Presenting with Debilitating Course Case Report of a Rare Condition Top


Ahmed M. Al Akwaa, A. Almulla, M. Yaguobi

Department of Medicine, Gastroenterology Unit, King Abdulaziz Hospital, Alahsa, Saudi Arabia

E-mail: [email protected]

Case Report: Visceral myopathy (VM) is a rare, pathological, and sometime misdiagnosed condition. It is characterized by signs and symptoms of intestinal obstruction without mechanical cause. The disease usually affects the smooth muscles of gastrointestinal tract and sometimes involves the urinary tract. It can be familial or sporadic. We report two brothers who developed chronic abdominal and urological symptoms with radiological, endoscopic, and pathological evidence of familial VM. The eldest is 26 years old while the youngest is 22 years. Both started to have the symptoms at age of 16–18 years. The eldest one has been investigated thoroughly in our center, and outside the kingdom, he had intestinal biopsy there with verbal report mentioning that he had VM. The youngest one had full-thickness gastric and small intestinal biopsy in our center that was consistent with VM. They fail to gain weight and their body mass index was 17. The two brothers had debilitating course with recurrent obstructive symptoms requiring admission to the hospital for 5–7 days, in vitro fertilization, prokinetic medications, and PPI. Medical treatment has been tried that gave variable responses. It seems that the disease is slowly progressive with increase in the symptoms as years go. Very effective treatment is not available till now, and management is usually symptomatic and supportive. It is a rare condition with few reported cases worldwide and no reported cases from Saudi Arabia.

[TAG:2]Abstract SJG2020/38: An Observational, Retrospective Cohort Study to Evaluate the Safety and Efficacy of Remsima In The Treatment of Inflammatory Bowel Disease Among Patients Diagnosed With Crohn'S Disease, Ulcerative Colitis, Or Fistulizing Crohn'S Disease[/TAG:2]

Shakir Bakkari, Thamer Al Darsoni, Ibrahim Al Razouqi, Reem AlShowair

Department of Medicine, Gastroenterology Unit, King Saud Medical Complex, Riyadh, Saudi Arabia

E-mail: [email protected]

Background: Inflammatory bowel disease (IBD), Crohn's disease (CD), and ulcerative colitis (UC) are chronic gastrointestinal diseases that further lead to the development of compromised quality of life, frequent surgical interventions, and further disease complications. One of the important therapeutic options considered for IBD is biological drugs which are high molecular size, structurally complex therapeutic agents that are obtained from live organisms. Methods: This was an observational, retrospective cohort study, which included 22 adult patients diagnosed with CD, UC, and fistulizing CD in the treatment of IBD. Information retrieved included the age at diagnosis, gender, nationality, and duration of the disease of 4 years, >4 years, and <4 years. Results: A total of 22 adult patients were diagnosed to have CD, UC, and fistulizing CD. For research and treatment purposes, CD has been divided into phenotypic subtypes: inflammatory, stricturing, and fistulizing. Effectiveness assessment was performed at baseline and at week 14 and week 30 of the treatment. The data collected for week 14 and week 30 were assessed for the endpoint of diagnosis of the disease status (active CD vs. fistulizing CD vs. UC) as well as naÏve versus switched status. The clinical response was measured by decrease in Crohn's disease activity index (CDAI) score from baseline of at least 70 score, or clinical remission (CDAI score <150). Conclusion: When low response to conventional therapies occurs, infliximab is indicated. Remisma® infliximab biosimilar has shown to be an effective alternative to original infliximab.


   Abstract SJG2020/39: Currently Available Noninvasive Tests Accurately Stage Fibrosis in Patients with Nonalcoholic Steatohepatitis Top


Stephen A. Harrison, Eric J. Lawitz1, Vincent Wai-Sun Wong2, Quentin M. Anstee3, Michael Trauner4, Manuel Romero-Gomez5, Raj Bhandari6, Manal F. Abdelmalek7, Arun J. Sanyal8, Keyur Patel9, Vincent Leroy10, Christophe Bureau11, Magali Sasso12, Celine Fournier12, Laurent Sandrin12, Ling Han13, Georgia Li13, Kathryn Kersey13, Marianne Camargo13, C. Stephen Djedjos13, Robert P. Myers13, Zachary Goodman14, Zobair M. Younossi14,15

Pinnacle Clinical Research, San Antonio, 1Texas Liver Institute, University of Texas Health San Antonio, TX, 6Delta Research Partners, Bastrop, LA, 7Duke University Medical Center, Durham, NC, 8 Virginia Commonwealth University, Richmond, 14Inova Fairfax Hospital, 15Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, 13Gilead Sciences, Inc., Foster City, CA, USA, 2Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, 3Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK, 4Division of Gastroenterology and Hepatology, Medical University of Vienna, Austria, 5Hospital Universitario Virgen del Rocio, Sevilla, Spain, 9University of Toronto, Toronto, ON, Canada, 10Centre Hospitalier Universitaire Grenoble, Grenoble, 11Centre Hospitalier Universitaire de Toulouse, Toulouse, 12Echosens, Paris, France

E-mail: [email protected]

Background: There is a major unmet need for accurate and readily available noninvasive tests (NITs) to stage fibrosis in patients with nonalcoholic steatohepatitis (NASH). Currently available NITs include physical biomarkers (BMs) such as liver stiffness measurement (LSM) by vibration-controlled transient elastography (VCTE), circulating BMs, or combinations of physical and circulating BMs such as the recently described FibroMeter VCTE. The aim of this study was to compare the diagnostic performance of currently available NITs to stage fibrosis in patients with NASH. Methods: The STELLAR studies enrolled patients with bridging fibrosis (F3) or compensated cirrhosis (F4) due to NASH (nonalcoholic fatty liver disease [NAFLD] activity score [NAS] =3). Screening liver biopsies were centrally read according to the NASH CRN classification, and NITs including LSM by VCTE, FibroMeter, FibroMeter VCTE, enhanced liver fibrosis (ELF) test, fibrosis-4 index, NAFLD fibrosis score, and AST-to-platelet ratio index were measured. The diagnostic performance of the NITs was described using areas under the receiver operating characteristic curves and compared using the Delong test. Global performance of the NITs was assessed using the Obuchowski index. Results: Among 1406 patients with available liver histology and NITs, 59% were female and the median (interquartile range) age and body mass index were 59 (13) years and 33 (9) kg/m2, respectively. Fibrosis stage distribution was: F0/F1: 4%, F2: 3%, F3: 43%, and F4: 49%. 94% of patients had NASH. AUROCs ranged from 0.77 to 0.87 to identify F =2, 0.71–0.85 for F =3, and 0.63–0.79 for F = 4 [Table 1]. Based on the Obuchowski index, FibroMeter VCTE significantly outperformed all other NITs followed by LSM by VCTE alone. Specialized blood tests alone, such as FibroMeter and ELF, performed similarly to simple composite blood tests. Conclusion: While single NITs generally performed well, the combination of a physical and a circulating BM of fibrosis (FibroMeter VCTE) significantly outperformed all other NITs for identification of F =2, F =3, and F4 in this cohort of patients with fibrosis due to NASH.


   Abstract SJG2020/40: Clinical Characteristics of Hepatitis B Virus Patients After Switching to Tenofovir Alafenamide Fumarate: A Retrospective Observational Study Top


Abdullah S. Alghamdi, Hammad Alothmani, Mohammed Mogharbel, Hazez Albiladi, Mohamed A. Babatin

Department of Medicine, Gastroenterology Unit, King Fahad Hospital Jeddah, Saudi Arabia

E-mail: [email protected]

Background: Hepatitis B virus (HBV) continues to be a significant global health problem despite vaccination programs and effective antiviral drugs.[ The study aim was to assess tenofovir alafenamide fumarate (TAF) as a new treatment modality in the light of the clinical characteristics of HBV patients. Methods: We performed a retrospective observational study on 71 HBV patients. For the primary endpoint, we recorded HBV-DNA plasma levels and biochemistry test results for ALT, AST, and serum creatinine levels at four time points including the baseline, the time of switching to TAF, 3 months after switching, and 6 months after switching. of the secondary endpoints, we recorded the reasons patients were switched to TAF and the number of recorded adverse events after switching. Results: from baseline to 6 months after switching to TAF, HBV-DNA plasma levels, ALT, AST, and serum creatinine levels were all significantly decreased. HBV-DNA levels dropped from 2 million to 16.7 IU/mL with a P < 0.05. ALT and AST levels dropped from 49.6 to 27 U/L and from 31 to 20.7 U/L with P = 0.025, and 0.032, respectively. Serum creatinine levels were lowered from 0.7 to 0.65 mg/dl with a P = 0.011. Secondary endpoint concluded that minimal reporting of side effects was one of the main reasons patients were switched to TAF and no reports of adverse events across all the study period were recorded. Conclusions: In the evaluated cohort, all clinical characteristics of HBV were improved 6 months after switching patients to TAF. No adverse events were reported throughout the study period.
Table 1: Diagnostic performance of noninvasive tests for fibrosis

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   Abstract SJG2020/41: Evaluation of Aspartate Aminotransferase-to-Platelet Ratio Index and Fibrosis-4 Score for Noninvasive Assessment of Significant Fibrosis In Chronic Hepatitis C As An Alternative to Transient Elastography Top


Ammar Al-Qadhi, Abdullah AlKhathlan

Department of Medicine, Gastroenterology Unit, King Fahd Medical City, Riyadh, Saudi Arabia

E-mail: [email protected]

Background: Ass?essment of? liver disease severity is important as the choice of treatment regimen and the posttreatment prognosis depend on the stage of fibrosis. We evaluated performance of fibrosis-4 and aspartate aminotransferase (AST)-to-platelet ratio index (FIB-4 and APRI) and compare it with using transient elastogrophy, (FibroScan) on chronic hepatitis C patients. Methods: This? was a sing?le-center retrospective study performed in tertiary care hospital in Riyadh, Saudi Arabia. Chronic hepatitis C patients who underwent FibroScan examinations were included. Demographic data were collected, including sex and age; serum alanine aminotransferase levels, serum AST levels, and platelet counts were also determined. The score of fibrosis was defined in kPa, classified based on cut-off value of 9 kPa (9 or more was considered positive for moderate fibrosis). The results of APRI and FIB-4 were compared with the FibroScan fibrosis scores. Results: The re?sults of ?145 patients were analyzed, including 84 (57.9%) males and 61 females (52.1%). A total of 52 patients (35.8%) were positive for fibrosis while 93 patients (66.2%) were negative for fibrosis. APRI and FIB-4 scores predicted liver fibrosis adequately using cut-off values of 0.5 and 1.5 (sensitivity 69.2%, specificity 77%, and sensitivity 34.6%, specificity 95.7%, respectively) and 1.45 and 3 (sensitivity 88.7%, specificity 80.6%, and sensitivity 38.4%, specificity 98.92%, respectively). Cutoff values of 3 for FIB-4 had a positive predictive value 95.24% for moderate fibrosis. Cutoff values of 1.45 for FIB-4 had a negative predictive value 88.24% for moderate fibrosis. Conclusions: FI?B-4 perform?ed well in assessment liver fibrosis. This noninvasive biochemical marker could be used as screening tool instead of FibroScan measurement.


   Abstract SJG2020/42: Colorectal Cancer Prevention In A Central Rural Area of Saudi Arabia, Al Kharj: Early Results Top


Abdulaziz Almasoud1,2, Omar Arahmane3, Jamaan Alzahrani4, Sameer AlGhamdi4, Ahmed AlShehri5, Pavlos Nikolaidis6, Abdullah Hamzah Bawazir7, Talal Alfayez7, Motaz Daadour7, Faisal Abdulmohsin7, Mohammed Abdulaziz Altaimimi7, Sami Munahi Alshalawi7, Georgios Zacharakis7

1Endoscopy Unit, Prince Sultan Military Medical City, 6Department of Computer and Information Sciences, Al-Imam Muhammad ibn Saud Islamic University, Riyadh, 2Departments of Gastroenterology, and 5Family Medicine, Al Kharj Military Hospital, 3Endoscopy Unit, King Khaled Hospital and Prince Sultan Center for Health Care, Al Kharj, 4Department of Family Medicine, College of Medicine, Prince Sattam bin Abdulaziz University, 7Department of Internal Medicine, Endoscopy Unit, College of Medicine, University Hospital, Prince Sattam bin Abdulaziz University, Al Kharj, Saudi Arabia

E-mail: [email protected]

Background: Incidence of colorectal cancer (CRC) is increasing recently in young people (<50 years) and the reasons are unknown and decreasing in population-based registries from high-income countries. In Saudi Arabia, there is no countrywide policy for CRC screening despite the increasing incidence of the disease. In this study, we aimed to adopt CRC screening program in a province of Riyadh, Al Kharj, with relatively large local population of >500,000. Methods: A guaiac fecal occult blood test (gFOBT) was preferably used in this study, which aims to identify microscopic blood in the stool, as the first-line noninvasive screening test to identify patients' gFOBT positive to be referred for colonoscopy. The Al Kharj Bowel Cancer Screening Program was implemented in 2018. By 2020, only first round run (screening every 2 years), all Saudis, aged 45–75 years will be offered colonoscopy, once FOBT(+) usually asymptomatic, regardless of their risk of developing CRC. Results: Positivity rate of FOBT(+) was 6.3% (83 positive). Out of the 63/83, colonoscopy was accepted 76% and refused by 35 (24%), all participants, all were gFOBT(+),average age 57 years (range 45–75), 49% were females (31/63), 76% were asymptomatic, 13% underwent sigmoidoscopy and 77% were well prepared. The prevalence of CRC was 4.8% (3/63), advanced adenoma 9.5% (6/63), adenoma 15.9% (10/63), nonadenoma polyps 7.9% (5/63), and no polyps or tumors 25.4% (16/63). Other findings were internal hemorrhoids 32% (20/63), colitis 24% (15/63) and diverticulosis 7.9% (5/63). There was male, age and left colon predominance of polyps and CRC. Conclusions: Low number of advanced adenomas and cancers has been detected in the first round of CRC screening. Screening participation was low and public education is probably necessary along with considerable colonoscopy resources. Causes of refusal were think about it 2.4%, need female endoscopist 2.4%. Afraid of pain, afraid of complications, does not believe in the test each in 0.6%. Does not want to know about result 1.2%. Causes of refusal were not clear from the record in 22 (14%). No correlation was found between age, gender, and refusal rate. Conclusion: In spite of initial agreement for involvement in colorectal screening, large number of patients refused to undergo screening colonoscopy. Rejection reasons were not clearly explored in this sample. Prospective well-designed study should be conducted in order to know the reasons and set proper intervention. The study disclosed the low level of awareness among Saudi society regarding CRC symptoms, risk factors, and screening. That social media is the most preferred way of spreading awareness for most participants.


   Abstract SJG2020/43: Knowledge and Awareness of Population Toward Nonalcoholic Fatty Liver Disease in Taif City, Saudi Arabia Top


Abdulhakeem S. Alamri, Majid Alhomrani, Maram O. Almerdas, Wafa A. Alghamdi, Waad F. Altwariqi, Najlaa M. Alosaimi, Shahad S. Alosaimi

College of Medicine, Taif University, Taif, Saudi Arabia

E-mail: [email protected]

Background: There has been an increase of nonalcoholic fatty liver disease (NAFLD) among population in Saudi Arabia; as in 2017, the prevalence rate of NAFLD has reached to 25%. There have been several studies conducted on NAFLD and its associated risk factors such as obesity and diabetes. However, there is a lack of studies on the knowledge and awareness of population towards the NAFLD. Therefore, the aim of this study is to assess the knowledge and awareness of population in Taif city. Methods: We used a questionnaire composed of 15 questions, which was distributed on general population (n = 400). All participants were both male (~30%) and female (~70%) and were older than 18 years. Results: A large proportion (~65%) of the respondents have poor knowledge about NAFLD before this survey. Around 25% of the respondents were thinking that NAFLD can lead to hepatocellular carcinoma. Further, there is high proportion (~45%) with little information that diabetes is a risk factor of NAFLD. Importantly, there is more than 70% of the respondents who were willing to undergo for NAFLD medical screening. Conclusion: This study shows limited knowledge and awareness about the NAFLD and its potential prognosis among population. This increases the importance of conducting education campaigns for the population about NAFLD to help the early detection and prevention liver diseases.


   Abstract SJG2020/44: Is Half Dose Corticosteroid Induction Therapy Effective in Achieving Therapeutic Response in Autoimmune Hepatitis? Top


Saad Aldosari, Ali Albenmousa1, Hamad Al-Ashgar2, Abduljaleel Alalwan3, Sarah Alfawaz4, Nouf Aldawsari4, Rahaf Alsofyani4, Faisal M. Sanai

Gastroenterology Unit, King Abdulaziz Medical City, 4Department of Medicine, King Abdulaziz Medical City, Jeddah, 1Department of Liver Transplantation and Hepatobiliary Surgery, King Faisal Specialist Hospital and Research Center, 2Department of Medicine, Gastroenterology Unit, King Faisal Specialist Hospital and Research Center, 3Department of Hepatobiliary Surgery and Liver Transplantation, King Abdulaziz Medical City, Riyadh, Saudi Arabia

E-mail: [email protected]

Background: Autoimmune hepatitis (AIH) is a chronic, progressive liver inflammation of unknown etiology. Guidelines recommend treatment initiation with either prednisone 40–60 mg monotherapy, or a lower dose of prednisone 30 mg combined with azathioprine (1–2 mg/kg) daily. Use of such higher doses of immunosuppression may increase the risk of side effects. In clinical practice, however, lower doses of prednisolone (30 mg/day) monotherapy are occasionally undertaken, although no data exist on its response rates. We aimed to study the achievement of biochemical response in patients with AIH who were initiated on prednisolone 30 mg or less as monotherapy. Methods: This is a multicenter, retrospective, observational study of patients with biopsy-proven AIH (n = 93). Patients were classified according to demographic variables, comorbid conditions, clinical presentation, degree of fibrosis, and biochemical values, into those who received prednisolone 30 mg/day monotherapy (low dose, n = 18) and those who received conventional dose prednisolone 60 mg/day or 30 mg/day combined with azathioprine (n = 75). The study endpoint was achievement of early biochemical remission defined as reduction in serum aminotransferases =50% of baseline after 1 month of treatment initiation. Results: The mean age of the overall cohort was 38 ± 16 years, of whom 54.8% were females, 36.6% presented with acute hepatitis, and 37.1% were cirrhotic. There were no differences in demographical or biochemical parameters, or mode of presentation and disease severity in both groups. At week 4, biochemical response was similar in the low-dose prednisolone group (61.1%) and the conventional dose group (69.4%, P = 0.576). There was no difference in response in those with mild–moderate fibrosis versus those with advanced fibrosis/cirrhosis (90.3 vs. 81.0%, P = 0.363). At week 12, biochemical response was also similar in both groups (68.8 vs. 70.7%, P = 1.00). At week 48, there was a trend toward higher response in the conventional dose group (90.3%) compared to the low dose group (72.7%), although it did not achieve statistical significance (P = 0.058). Conclusion: Achievement of early on-treatment biochemical response is similar in patients receiving low-dose corticosteroid monotherapy or the conventional doses of immunosuppression. Lower dose corticosteroid monotherapy may be cautiously adopted until its wider impact can be validated in larger, randomized controlled clinical trials.


   Abstract SJG2020/45: Characteristics of Upper Gastrointestinal Bleeding: A 13-Year Retrospective Study Top


Ibrahim Alruzug, Thamer Aldarsouny, Taufic Semaan, Manhal Aldaher, Asma Alnajjar

Department of Medicine, Gastroenterology Unit, King Saud Medical City, Riyadh, Saudi Arabia

E-mail: [email protected]

Background: Upper gastrointestinal bleeding (UGIB) is a common problem that leads to prominent medical emergencies with substantial morbidity and mortality. The aim of this study was to determine the most common source of UGIB in Saudi patients according to their demographic characteristics over a 13-year period. Methods: This retrospective study analyzed the data of all patients who underwent gastroscopy for UGIB at King Saud Medical City Hospital, Riyadh, Saudi Arabia, between January 2004 and December 2016. The patients were directed from various sources, such as the emergency room, or referred from other departments/centers as inpatients. The demographics, indications, and endoscopic findings of the patients were analyzed. Results: A total of 2075 patients' medical records were evaluated [Table 1]. Among them, 1408 patients were males (67.9%); majority of patients were referred from the emergency room or were inpatients (93.6%). The median age of all patients was 57.66 years. More than half the patients presented with hematemesis (52.5%, P =0.02375), whereas 31.2% had melena, 15.1% both hematemesis and melena, and 1.2% hematochezia. The most common sources of bleeding were gastroduodenal erosions (23.8%), duodenal ulcers (23.4%), reflux esophagitis (16%), esophageal varices (12.1%), and gastric ulcers (10.7%). About 65.9% of patients had various comorbidities, P = 0.0001. Conclusion: This study found that peptic ulcer disease is the most common etiology of UGIB among Saudi patients from the Central region of Saudi Arabia. Implementing programs for treating risk factors of peptic ulcer disease could help decrease the incidence of UGIB in Saudi patients.


   Abstract SJG2020/46: Characteristics of Colonic Polyps Among Patients in King Saud Medical City: A Prospective Study Top


Ibrahim Alruzug, Asma Alnajjar, Toufic Semaan, Manhal Aldaher, Thamer Aldarsouny, Saeed Zubaidi, Shakir Bakkari, Adnan Almustafa, Awad Shehata

Department of Medicine, Gastroenterology Unit, King Saud Medical City, Riyadh, Saudi Arabia

E-mail: [email protected]

Background: Studies reporting the prevalence and characteristics of polyps in the Eastern countries, in particularly Saudi Arabia, are limited. This study is the first, prospective study to review both the endoscopic and histological characteristics of polyps as well as patients' demographics in a tertiary care center in Saudi Arabia. Methods: This prospective, cohort study was conducted between January 2018 and January 2019, at King Saud Medical City, Riyadh, Saudi Arabia. A registry of all patients who had colonoscopies, both elective and emergency, was created. The demographics, indications, and endoscopic findings of the patients as well as the number, site, size, and histopathology of lesions were recorded and analyzed. Results: Out of 746 patients who underwent colonoscopies, 226 patients (30.29%) had polyps. The average age of screening was 49 years. PR bleeding, constipation, and abdominal pain were the most common indications for screening. Majority of polyps were adenomas (111; 95% confidence interval 12.4–17.6%), hyperplastic (45), and inflammatory (24). The adenoma detection rate was 14.88%, regardless of age. Ninety-six out of 174 patients above 45 years of age had adenomatous polyps, with a male-to-female ratio of 2:1. Only 15 patients less than the age of 45 had adenomatous polyps. The left colon was the most common site involved. Conclusion: In comparison to similar data found in Western studies, adenomatous polyps were the most common type of polyps found in patients undergoing screening colonoscopies. However, the ADR remains way less than that in Western countries.
Table 1: Demographic and clinical profile of study patients

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   Abstract SJG2020/48: The Burden of Positive Celiac Serology: Experience of a Single Health Care Provider in Saudi Arabia Top


Diamond Joy, Mohammed Al-Edreesi, Carole A Merriwether

Department of Gastroenterology, Johns Hopkins Aramco Hospital, Dhahran, Saudi Arabia

E-mail: [email protected]

Background: Although celiac disease has been well described in various parts of the world, there are limited studies looking at the disease burden from a healthcare provider setting in the Middle East region. Our aim was to determine the burden of positive celiac serology from our health care in the eastern province of Saudi Arabia. Methods: This study was conducted at our center after obtaining ethical approval from the institutional review board. The duration of the study was from June 2002 to December 2019 and included all patients receiving care at Johns Hopkins Aramco Healthcare. Those tested positive for transglutaminase antibody (TTG antibodies; Mayo Clinic laboratories) were identified. Patient demographics were analyzed. Results: of the 10,422 patients tested during this study period, positive TTG result was reported in 210 patients (2.0%). It was found that the number of positive tests was increasing each year. 139 were females and 71 were males. Women were more likely to have a positive test (P < 0.05). Positivity was significantly more when tested by an endocrinologist when compared to gastroenterologists or other physicians (P = 0.004). 65 patients (31%) were in the pediatric age group (<14 years). Among pediatric age group, 41 (63%) were females. Most of the patients with abnormal test result were Saudi Nationals (>85%).Conclusion: Celiac disease is not an uncommon condition in health care provider setting. Our study suggests that celiac disease is under-recognized. Targeting the use of celiac serology can help diagnose more patients with celiac disease.


   Abstract SJG2020/49: Frequency of Neutropenia in Patients Treated with Infliximab Leading to Temporary Hold of Medication: A Single-Center Experience Top


M. AlMousa, Ahmed Alakwaa, W. AlSwailem

Department of Medicine, Gastroenterology Unit, King Abdulaziz Hospital, Alahsa, Saudi Arabia

E-mail: [email protected]

Background: Infliximab as an anti-tumor necrosis factor (TNF) biologic therapy has greatly improved and changed the course of inflammatory bowel disease and some rheumatological conditions. Various side effects limit the use of infliximab. Patients may rarely develop neutropenia that mandate holding injection for weeks, leading to reactivation of the controlled disease. We aimed to determine the frequency of neutropenia in patients' receiving infliximab and effect on further management and to estimate the effect of azathioprine on these subjects. Methods: This study was a retrospective analysis of electronic records for patients receiving Infliximab. Patients' history, examination, diagnosis, comorbidities, laboratory tests including CBC, LFT, medications taken, response to treatment, and actions done in case of neutropenia were collected. WBC <4000 and PNL <1500 were considered leukopenia and neutropenia. Patients with neutropenia will be rescheduled to receive injection later. Results: Twenty-eight patients receiving infliximab recruited. Four excluded. 62% were males. Mean age was 33.6 years (15–58). Diagnosis of Crohn's disease, ulcerative colitis, and psoriatic arthritis were in 18, 5, and 1 patient, respectively. Diabetes mellitus and hypertension were seen in only 8%. Mean duration of infliximab injections was 47 months (4 months–11 years). One-third of the patients were on azathioprine. None was on prednisolone. Postinfliximab LFT were normal. Significant neutropenia (0.7–1.3) has been seen in 4 patients (16.6%). None of the patients on azathioprine developed neutropenia. There was no apparent association with the use of other medication and neutropenia. No relation between the length of infliximab use and neutropenia was noted. Conclusion: The frequency of neutropenia leading to delaying infliximab injection is notably higher than reported in the literature; this might have negative impact on patients' management. Preinjection CBC is necessary; however, LFT is not. Larger sample size is needed to validate this observation.

[TAG:2]Abstract SJG2020/50: The Prevalence of Upper Digestive Symptoms, Comorbidities, Helicobacter Pylori Infection, and Abnormal Endoscopic Findings Resulted in Modified Management in Bariatric Centers of Kingdom of Saudi Arabia. Why All Patients Should Be Scope Routinely?[/TAG:2]

Georgios Zacharakis, Abdulaziz Almasoud1, Jamaan AlZahrani2, Sameer AlGhamdi2, Abdullah AlShehri3, Alexandros Kyritsis4, Abdullah Altuwaim, Ahmed Lotfy4, Ahmad Alonazi, Nasser Mohamed Alajmi, Abdullah Faisal Alsamari, Ioannis Terzis4

Department of Medicine, Endoscopy Unit, College of Medicine, Prince Sattam bin Abdulaziz University Hospital, 3Department of Family Medicine, Military Hospital, 4Department of Family Medicine, College of Medicine, Prince Sattam bin Abdulaziz University Hospital, Al Kharj, 1Endoscopy Unit, Prince Sultan Military Medical City, Riyadh, 5Bariatric Clinic, King Salman Specialist Hospital, Hail, Saudi Arabia

E-mail: [email protected]

Background: Preoperative esophagogastroduodenoscopy (EGD) has not been consistently shown to change the management of the bariatric patient because of different morbidity among countries. The present prospective study evaluated the prevalence of preoperative EGD findings in Saudi obese patients including upper digestive symptoms (UDSs), comorbidities, and the effect of them on changing the planned surgery. Methods: During the period of January 2018 to May 2019, a two-center prospective study evaluated Saudi obese patients, aged 18–65 years and body mass index (BMI) >4. The patients' preoperative data included UDS, comorbidities, Helicobacter pylori (HP) infection assessed at histopathological examination and EGD findings. Results: Overall, 717 enrolled patients underwent EGDs and 432 underwent bariatric surgery; 240 patients at Bariatric Clinic of King Salman Specialist Hospital in Hail and 192 at Al Kharj Military Hospital. Type of bariatric procedure was vertical sleeve gastrectomy (SG): 402 and Roux-en-Y gastric by pass (RYGB): 30. The rest remained in waiting list. Mean BMI was 44.3 ± 6.3 and the mean age was 27.8 ± 11.8 years old. The predominant gender in obesity was the female (65%). Overall, 38% had at least one or more comorbid diseases. More than a half of patients reported diabetes mellitus type II (57%) followed by hypertension (50%) and chronic back pain (32%). Depression and anxiety were less reported (11%). Regarding the UDS, the overall prevalence was 49%. The most frequent UDS was gastroesophageal reflux disease (GERD) 54% (387/717) followed by dyspepsia symptoms 44% (315/717). HP infection was positive in 287/672 (42.4%) patients. Based on preoperative EGD findings, total patients with normal EGD were 36% (258/717). of those patients who underwent bariatric surgery had no delay or modified procedure. Delayed bariatric procedure had 15.04% (65/432) patients due to large polyps >1 cm (either hyperplastic or cystic polyps) 2.3% (10/432), and esophagitis LA C and D 1.62% (7/432); Barrett's esophagus was present in 0.7% (3/432) or peptic ulcers in 5.7% (25/432). Modified Bariatric procedure needed in 64/432 (14.8%) but only almost half 47% (30/64) with medium-sized and large hiatal hernia and GERD symptoms with esophagitis (9.7%) underwent RYGB. The rest (34) refused to change the bariatric procedure and underwent SG that is the most popular in Saudi Arabia. Bariatric procedure contraindicated in 9 (1.27%) patients with varices 7/717 (0.97%) and malignant lesions 2/717 (0.27%). Conclusions: (A) Almost two-third reported comorbidities with female predominance. Our findings confirmed that obesity carry a profound health burden and will have a significant impact on health expenditures. (B) Almost half of them had UDS. (C) High rates of HP reported in the Saudi obese patients. (D) Routine, preoperative EGD in obese Saudi population appears mandatory to identify factors that change the bariatric procedure, delayed, or postponed it.


   Abstract SJG2020/51: Upper Gastrointestinal Bleeding Secondary to Sevelamer-Induced Esophagitis: A Case Report Top


Amany AlAmoudi1, Ammar AlDabbagh1, Salem Bazarah1,2

1Department of Medicine, Dr. Soliman Fakeeh Hospital, 2Department of Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia

E-mail: [email protected]

Case Report: The prevalence and incidence of end-stage renal disease (ESRD) in Saudi Arabia are sharply increasing. Sevelamer is a noncalcium-containing phosphate binder used to manage hyperphosphatemia in ESRD. Sevelamer is known to cause mucosal depositions throughout the gastrointestinal tract with varying levels of symptoms associated. The common side effects include abdominal pain, dyspepsia, vomiting, and an extremely rare gastrointestinal (GI) bleeding. We report the first case of sevelamer-induced upper GI bleeding from severe esophagitis confirmed with biopsy. A 42-year-old comorbid female diagnosed to have bladder cancer and chronic kidney disease secondary to obstructive uropathy. She was referred to gastroenterology service as a case of upper GI bleeding in form of coffee ground emesis with drop of hemoglobin level to 5.8 g/dl. An urgent upper endoscopy showed extensive ulcerated and sloughed esophageal mucosa [Figure 1]. Biopsies were obtained to rule out the infectious etiologies. Histopathological examination was consistent with diagnosis of sevelamer-induced esophagitis. Discussion: Sixteen cases of sevelamer-induced GI injury have been reported in the literature. The most affected GI segment was the colon. To our knowledge, this is the first reported case of upper GI bleeding caused by sevelamer-induced esophagitis.


   Abstract SJG2020/52: Characteristics and Correlates of Portosystemic Collaterals in Patients with Cirrhosis and Portal Hypertension and the Novel Msct-Based Assiut Classification of Splenic Collaterals Top


Ahmed Helmy, Aya Mohamed Mahrous, Reem Mohamed Ali1, Yousef Mohamed Sweefi, Amal Ahmed Helmy1, Yehia Taha Kishk2

Departments of Tropical Medicine and Gastroenterology, 1Radiology and 2Cardiology3, Assiut University Hospitals, Assiut, Egypt

E-mail: [email protected]

Background: Development of portosystemic collateral veins (PSCVs) in patients with portal hypertension (PHT) is implicated in pathogenesis of bleeding varices and hepatic encephalopathy (HE). PSVCs are scarcely studied. This study characterizes PSCVs using MSCT and assesses their correlations with liver function, splenic size, and the development of varices, HE, hepatocellular carcinoma (HCC), hepatic venous-pressure-gradient (HVPG). It also presents a novel classification of splenic collateral veins (SCVs); “Assiut Classification.” Methods: A case–control study involving 100 patients with cirrhosis and PHT with (n = 50) or without (n = 50) PSCVs detected by using MSCT. Direct transjugular HVPG was measured in 10 patients with (n = 5) or without (n = 5) PSCVs using  Swan-Ganz catheter More Detailss. Results: A total of 47(94%) of the patients with PSVCs had SCVs, which were classified according to their site (hilum, upper pole, lower pole), and shape (grape-like, serpiginous, worm-like). Compared to patients without PSVCs, those with PSVCs has significantly less endoscopically-detectable gastroesophageal varices (58% vs. 92%; P < 0.001), more hemorrhoids (48% vs. 20%; P < 0.001), higher rate of HCC (88.2% vs. 11.8%; P < 0.001), more HE recurrence (4.9 ± 2.4 vs. 2.8 ± 1.62% attacks in 6 months; P < 0.001), lower HVPG (2.2 ± 1.6 vs. 12.8 ± 1.6 mmHg; P < 0.001), but similar splenic size (14.7 ± 2.8 vs.14.8 ± 0.9 cm; P = 0.788), respectively. Conclusions: MSCT accurately delineates PSVCs, and SCVs are the most common. Clinical significance of SCVs classification needs further investigated. Patients with PSVCs may require less variceal endoscopic surveillance, more HCC screening, and prolonged HE prophylaxis.


   Abstract SJG2020/53: Survival Benefit of Nivolumab as a Second-Line Treatment After Failure of Sorafenib in Patients with Unresectable Hepatocellular Carcinoma Top


Hassan O. Odah, Kanan Alshammari1, Adnan Alzanbaqi2, Murooj Alsubhi3, Ashwaq Alolayan1, Ahmed Alshehri4, Faisal M. Sanai

Department of Medicine, Gastroenterology Unit, King Abdulaziz Medical City, 2Department of Medical Imaging, King Abdulaziz Medical City, 4Medical Oncology Unit, Princess Noura Oncology Center, King Abdulaziz Medical City, Jeddah, 1Ministry of National Guard– Health Affairs, Riyadh, 2Department of Medicine, Gastroenterology Unit, King Abdullah Medical City, Makkah, Saudi Arabia

E-mail: [email protected]

Background: Limited data exists on systemic treatments for patients with hepatocellular carcinoma (HCC) whose disease progresses during sorafenib therapy. The US Federal Drug Administration recently approved nivolumab for HCC as a second-line treatment after failure of sorafenib. We aimed to assess the efficacy and safety of nivolumab in patients with HCC who have progressed during sorafenib treatment in a real-life cohort. Methods: In this retrospective, observational, multicenter study, adult Child-Pugh A/7B patients with HCC who tolerated sorafenib (n = 79) therapy but progressed were started on nivolumab (n = 40). A similar number of consecutive, unselected patients who were maintained on sorafenib therapy, regardless of disease response or progression, were used as historical controls (n = 39). Patients were assessed in terms of Eastern Cooperative Oncology Group (ECOG) performance status, macrovascular invasion, extrahepatic disease, and a-fetoprotein level to best supportive care plus oral sorafenib or intravenous nivolumab as the second-line therapy. The primary endpoint was overall survival (defined as time from starting sorafenib in either group, up to death due to any cause) and analyzed by intention-to-treat. Results: The mean age of the overall cohort was 69.0 ± 9.0 years, of whom 86.1% were males and 58.2% had underlying viral etiology. Patients who received nivolumab were more likely to have comorbidities (70.0 vs. 15.4%), higher ECOG status (85.0 vs. 64.1%), and extravascular invasion (51.3 vs. 12.8%; P < 0.05 for all). Patients who received nivolumab were more likely to have higher Child-Pugh status (CTP 7B; 38 vs. 26%), although this did not reach statistical significance (P = 0.372). Median survival was significantly higher in patients who received nivolumab compared to sorafenib [21.0 vs. 9.0 months, P = 0.0134, [Figure 1]]. Median survival after starting nivolumab was 9 months. Conclusion: Nivolumab is an effective second line treatment option in unresectable HCC patients who progress on sorafenib, with significantly improved overall survival. These early real-life data offer encouraging results for nivolumab as second-line therapy for HCC progressing on sorafenib therapy and are similar to those shown in Phase 1/2a clinical trials. Data from larger, multicenter, randomized controlled, Phase 3 clinical trials are awaited for further assessment of the survival benefits.
Figure 1: (a and b) Endoscopic features of extensive ulcerated and sloughed esophageal mucosa. (c) LPF: Histological features showing extensive mucosal ulceration with multiple fragments of sevelamer resin seen among the ulcer fibrino-inflammatory debris. (d) HPF: sevelamer resin revealing its characteristic two-toned color and “fish-scale” pattern

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   Abstract SJG2020/54: Inflammatory Cloacogenic Polyp: A Rare Mimicker of Rectal Cancer Top


Mansour Alourfi, Mahmoud Mosli

Department of Medicine, Gastroenterology Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia

E-mail: [email protected]

Case Report: An 18-year-old girl was referred to the hospital with generalized fatigue and symptomatic anemia. The patient reported chronic history of bleeding per rectum for the last 3 years associated with chronic constipation and straining during defecation. The patient went to many different local hospitals with no conclusive diagnosis and received symptomatic treatment with no improvement in her condition. The digital rectal examination was normal. Laboratory tests showed hemoglobin level of 4.9; rest of her laboratories was within normal limits. Rectal retroflexion during colonoscopy examination showed a neoplastic looking ulcerated polypoid mass arising from the dentate line [Figure 1]. Multiple biopsies were taken. Histopathology of biopsies revealed extensive superficial ulceration and villiform change, crypt hyperplasia, as well as fibromuscular hyperplasia of lamina propria with no dysplasia present [Figure 2, H and E, ×100]. Based on these findings, a diagnosis of inflammatory cloacogenic polyp was made. The patient was referred for surgical resection of the polyps.


   Abstract SJG2020/55: Hospital-Based Economic B? Urden of Inflammatory Bowel Diseases in Saudi Arabia: A Patient Perspective Study Top


Mahmoud Mosli

Department of Medicine, Gastroenterology Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia

E-mail: [email protected]

Background: The inflammatory bowel diseases (IBD), ulcerative colitis (UC), and Crohn's disease (CD) are chronic gastrointestinal diseases characterized by an exacerbated inflammatory cell infiltrate in the gut mucosal tissue. The medical management of the UC and CD can incur considerable healthcare resources and costs. Despite that a large proportion of patients that are diagnosed with IBD in Saudi Arabia are treated with biologics, no available data exist that highlights the economic burden of IBD treatment in Saudi Arabia. The main objective of this study was to assess the economic burden of IBD from payer perspective in the Kingdom of Saudi Arabia. Methods: Management data were obtained from an analysis of the IBD information system registry from King Abdulaziz University's Hospital. The total burden was calculated from the cost of monitoring, treatment, and consultation utilized during the patient treatment between 2018 and 2019. The cost of medications was based on registered prices as per the Saudi FDA price list. Results: One hundred and sixty-six patients (50.6% male and 49.4% female) with a mean age of 29 years were included in this study. CD represented 71% and UC 29% of the cohort. The mean annual cost (2018–2019) of IBD per patient was SAR 58,631 ($15,635). Treatment cost accounted for 92.8% of the total cost, 5% for monitoring, and 2.2% for outpatient visits during the follow-up. The average annual medical cost per patient for CD and UC was estimated at SAR 61,699 ($16,453) and SAR 51,088 ($13,623), respectively. Conclusions: IBD represents a significant burden on the society, shedding the light on the incurred costs through this model can inform decision-makers about efficient resource allocation for patients suffering from IBD.
Figure 1: Kaplan–Meir analysis of overall survival in patients receiving sorafenib and nivolumab

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   Abstract SJG2020/56: Prevalence of Gastroesophageal Reflux Disease: A Prospective University Hospital-Based Study Top


Abdulaziz M. Alrezuk1, Raed M. AlGhazal2, Ioannis Anastasiou3, Raed M. Alsulaiman1,6, Mona H. Ismail1,6, Mariam D. Seria4, Hassan J. Alzahrani5, Salim M. Bawazeer2, Abdulaziz A. Al-Quorain1,6

1Department of Internal Medicine, Division of Gastroentrology, King Fahd Hospital of the University, 2Department of Internal Medicine, Division of Gastroentrology at King Fahd Specialist Hospital, 5Division of Gastroentrology, Dammam Medical Complex, 6College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, 4Division of Gastroentrology, King Fahd Military Medical Complex, Dhahran, Saudi Arabia, 3GIT and Hepatology Division, University of Arkansas for Medical Sciences, Arkansas, United States

E-mail: [email protected]

Background: Gastroesophageal reflux disease (GERD) is a chronic disorder with an increasing disease burden and a prevalence ranging between 15% and 25%. Data on GERD among adult patients from Saudi Arabia are scarce. Our aim was to prospectively estimate the prevalence of GERD among all adult patients scheduled for upper gastrointestinal endoscopy for dyspeptic and reflux symptoms. Methods: This prospective observational study included all adult patients scheduled for esophago-gastro-duodenoscopy at King Fahd Hospital of the University, Al Khobar, Saudi Arabia, during a period of 6 months. The sociodemographic data and upper gastrointestinal endoscopy findings were assessed for all the patients. Descriptive data were represented as frequencies and percentages. Results: We evaluated a total of 200 (62.5% female and 37.5% male) patients. The mean age group was 44.8 ± 16.1 years. The majority were Saudi (91.5%) and nonsmokers (85.5%). Sixty-six percent had body mass index <30 kg/m2. Epigastric pain, regurgitaion, pyrosis, and flatulence were the most frequent symptoms observed. The mean duration of the symptoms was 40.3 months (range: 1–192 months). Stomach-endoscopy findings revealed chronic gastritis in 69.5% patients. Helicobacter pylori infection was present in 76% of the patients. The most common histopathological findings were mild chronic gastroduodenitis (69.5%) and moderate chronic gastritis (13.5%). The GERD prevalence in the current study was 20%. The majority of the patients were treated with proton pump inhibitors (98%). Conclusion: GERD symptoms are common in our cohort. The reported prevalence of GERD in the current study was 20%.
Figure 1: Polypoidal mass arising from the dentate line seen during colonoscopy

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Figure 2: Histopathology (H and E stain) of the biopsied mass

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-3767.297661

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