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2.  Advanced Endoscopic Imaging for Surveillance for Dysplasia and Colorectal Cancer in inflammatory Bowel Disease: Could the Pathologist be Further Helped? 
Patients with inflammatory bowel disease (IBD) have an increased risk of developing intestinal cancer. The magnitude of that increased risk as well as how best to mitigate it remain a topic of ongoing investigation in the field. It is important to quantify the risk of colorectal cancer in association with IBD. The reported risk varies widely between studies. This is partly due to the different methodologies used in the studies. Because of the limitations of surveillance strategies based on the detection of dysplasia, advanced endoscopic imaging and techniques involving the detection of alterations in mucosal antigens and genetic abnormalities are being investigated. Development of new biomarkers, predicting future occurrence of colonic neoplasia may lead to more biomarker-based surveillance. There are promising results that may lead to more efficient surveillance in IBD patients and more general acceptance of its use. A multidisciplinary approach, involving in particular endoscopists and pathologists, together with a centralized patient management, could help to optimize treatments and follow-up measures, both of which could help to reduce the IBD-associated cancer risk.
doi:10.4103/1319-3767.126314
PMCID: PMC3952417  PMID: 24496155
Colorectal cancer; Crohn's disease; inflammatory bowel disease; surveillance; ulcerative colitis
3.  The Role of Esophageal Stent Placement in the Management of Postesophagectomy Anastomotic Leak 
Background/Aim:
Anastomotic leak after esophagectomy is one of the most challenging complications resulting in a high morbidity and mortality and prolonged hospitalization. The study intended to assess the outcome of endoluminal self-expanding stent in the treatment of this problem.
Settings and Design:
Department of Thoracic and Cardiovascular Surgery, Arhus University Hospital, Skejby, Arhus, Denmark. A retrospective study.
Patients and Methods:
From January 2007 to December 2010, 209 patients underwent esophagectomy for malignant disease of the esophagus or the cardia. Twenty patients developed anastomotic leak. Treatment consisted of conservative measures, surgery, and stent placement. Details of treatment, clinical outcome, complications, and mortality were evaluated.
Statistical analysis:
None.
Results:
One hundred and forty-seven patients (70.3%) had carcinoma of the cardia, whereas 62 patients (29.7%) had esophageal carcinoma. Twenty patients (9.5%) developed anastomotic leak; small (<1 cm) in two patients (10%); managed conservatively and bigger than 1 cm in 15 patients (75%); treated with an esophageal stent (Hanaro stent, DIAGMED Healthcare, Thirsk, YO7 3TD, United Kingdom). In three patients (15%), perforation of the staple line of the intrathoracic gastric conduit was found and managed by reoperation. Functional sealing of anastomoses after stent placement could be achieved in 10 patients (67%). Stent-related morbidity developed in five patients (33%): Migration of the stent, n=3 and tracheoesophageal fistula, n=2. Stents were smoothly removed 3 weeks after discharge. The mean hospital stay was 25 days. There was only one stent-related death (6.6%).
Conclusion:
Endoluminal stent implantation is an effective and safe option in the management of postesophagectomy leaks.
doi:10.4103/1319-3767.126315
PMCID: PMC3952418  PMID: 24496156
Anastomosis; esophagus; endoscopy
4.  Efficacy of Pneumatic Dilatation in Saudi Achalasia Patients 
Background/Aims:
Pneumatic dilatation (PD) is one of the effective treatments of achalasia. The aim of this study was to evaluate the efficacy of pneumatic dilation and patient satisfaction in Saudi achalasia patients.
Patients and Methods:
We have retrospectively recruited patients with confirmed achalasia, who underwent at least one dilatation session from January 1990 to January 2010 at a single tertiary center. Symptoms, including weight loss, dysphagia, retrosternal pain, and regurgitation, were assessed with the use of the Eckardt score (which ranges from 0 to 12, with higher scores indicating more pronounced symptoms). All patients were called and asked about their Eckardt score in addition to their satisfaction score post the dilatation procedure. The primary outcome was therapeutic success (Eckardt score ≤ 3) and patient satisfaction at the time of their calls. The secondary outcomes included the need for retreatment and the rate of complications.
Results:
A total of 29 patients were included, with a mean age of 40.30 (95% CI: 36.1-44.6) and 55.2% of them were males. The mean of the pre-dilatation Eckardt score was 8.3 (95% CI: 7.2-9.4), which dropped to 2.59 (95% CI: 1.7-3.5) after PD (P < 0.01) with a clinical remission of 76.7% after the first dilatation and a total failure in two patients (7%) after the third dilatation. The mean number of dilatations was 1.3 (95% CI: 1.1-1.5) where 50.7% required one dilatation, 19.2% required two dilatations, and 30.1% required three dilatations. The mean of the symptoms-free period was 53.4 months (SD 52.7, range 1-180) with symptoms recurring in 35% of patients within 2 years. The mean of post-PD patient satisfaction was 7.45 (95% CI: 6.2-8.7). Perforation, which was treated conservatively, occurred in one patient (3.5%), whereas bleeding occurred in two patients (7%). Age or gender was not found to be a predictor of Eckardt score improvement on multivariate linear regression analysis.
Conclusion:
PD is an efficacious procedure in Saudi achalasia patients with a very good overall patient satisfaction with 53.4 months of symptoms-free period after a successful dilatation.
doi:10.4103/1319-3767.126317
PMCID: PMC3952419  PMID: 24496157
Achalasia; dilatation; eckdart score; esophagus; pneumatic dilatation
5.  Prognostic Significance of Glasgow Prognostic Score in Patients Undergoing Esophagectomy for Esophageal Squamous Cell Carcinoma 
Background/Aims:
Recent studies have revealed that Glasgow prognostic score (GPS), an inflammation-based prognostic score, is inversely related to prognosis in a variety of cancers; high levels of GPS is associated with poor prognosis. However, few studies regarding GPS in esophageal cancer (EC) are available. The aim of this study was to determine whether the GPS is useful for predicting cancer-specific survival (CSS) of patients for esophageal squamous cell carcinoma (ESCC).
Patients and Methods:
The GPS was calculated on the basis of admission data as follows: Patients with elevated C-reactive protein (CRP) level (>10 mg/L) and hypoalbuminemia (<35 g/L) were assigned to GPS2. Patients with one or no abnormal value were assigned to GPS1 or GPS0, respectively.
Results:
Our study showed that GPS was associated with tumor size, depth of invasion, and nodal metastasis (P < 0.001). In addition, there was a negative correlation between the serum CRP and albumin (r = −0.412, P < 0.001). The 5-year CSS in patients with GPS0, GPS1, and GPS2 were 60.8%, 34.7% and 10.7%, respectively (P < 0.001). Multivariate analysis showed that GPS was a significant predictor of CSS. GPS1-2 had a hazard ratio (HR) of 2.399 [95% confidence interval (CI): 1.805-3.190] for 1-year CSS (P < 0.001) and 1.907 (95% CI: 1.608-2.262) for 5-year CSS (P < 0.001).
Conclusion:
High levels of GPS is associated with tumor progression. GPS can be considered as an independent prognostic factor in patients who underwent esophagectomy for ESCC.
doi:10.4103/1319-3767.126319
PMCID: PMC3952420  PMID: 24496158
Esophageal squamous cell carcinoma; glasgow prognostic score; prognostic factor; survival
6.  SASLT Practice Guidelines for the Management of Hepatitis B Virus 
doi:10.4103/1319-3767.126311
PMCID: PMC3952421  PMID: 24496154
Guidelines; hepatitis B virus; Saudi Association for the Study of Liver diseases and Transplantation
7.  Association of Plasminogen Activator Inhibitor-1 Gene Polymorphism with Inflammatory Bowel Disease in Iranian Azeri Turkish Patients 
Background/Aim:
Previous studies have shown the association of some genetic factors, such as Plasminogen activator inhibitor type-1 (PAI-1) 4G/5G polymorphism, with the development of inflammatory bowel disease (IBD). We aimed to study this polymorphism as a risk factor in IBD patients in this cohort.
Patients and Methods:
One hundred and fifteen IBD patients and 95 healthy controls were selected from Iranian Azeri Turks and -6754G/5G polymorphism of PAI-1 gene was tested by polymerase chain reaction using allele-specific primers confirmed by sequencing.
Results:
There was no significant difference of PAI-1 polymorphism between IBD patients and the control group (P > 0.05). Furthermore, these data showed no significant difference between Crohn's disease and ulcerative colitis patients. However, 4G/4G homozygotes have reduced probability to progression of loss of appetite, whereas 5G/5G genotypes have increased risk for development of chronic diarrhea without blood, nausea, and loss of appetite.
Conclusions:
Although our study showed no significant association of PAI-1 polymorphism between patients and control group, the carriers of 4G/4G genotype and 4G allele had reduced risk for the progression of IBD features in this cohort.
doi:10.4103/1319-3767.126322
PMCID: PMC3952422  PMID: 24496159
Inflammatory bowel disease; Iranian Azeri Turks; plasminogen activator inhibitor 1; 4G/5G polymorphism
8.  Overexpression of Cyclooxygenase-2 and Transforming Growth Factor-Beta 1 is an Independent Predictor of Poor Virological Response to Interferon Therapy in Chronic HCV Genotype 4 Patients 
Background/Aims:
COX-2 and TGF-β1 are overexpressed in hepatitis C virus (HCV) infection and are related to hepatitis pathogenesis and hepatic fibrosis. The current study investigated the relationship between pretreatment COX-2 and TGF-β1 hepatic expression in HCV genotype 4 and the virological response to interferon therapy.
Patients and Methods:
Liver biopsies of 55 patients with HCV infection genotype 4 were selected together with 10 liver biopsies as control. The patients’ clinicopathological data were collected. Immunohistochemistry was done using anti-COX-2 and anti-TGF-β1 antibodies. Statistical tests were used to determine the association between both COX-2 and TGF-β1 expression in relation to clinicopathological parameters and response to interferon therapy.
Results:
COX-2 was upregulated especially in nonresponders and was an independent predictor of poor virological response. However, COX-2 showed no association with other clinicopathological features. TGF-β1 was upregulated and associated with nonresponders, histological activity, and fibrosis stage. There was no association between TGF-β1 and other clinicopathological features. There was an association between COX-2 and TGF-β1 immunoexpression.
Conclusion:
Overexpression of COX-2 and TGF-β1 is an independent predictor for poor outcome of interferon and ribavirin therapy and these might be useful markers for the response to treatment. Both molecules are associated together; however, their role during hepatitis treatment has to be clarified.
doi:10.4103/1319-3767.126324
PMCID: PMC3952423  PMID: 24496160
Chronic hepatitis; cyclooxygenase-2; hepatitis C virus genotype 4; immunohistochemistry; transforming growth factor-beta1; virological response
9.  Evaluation of Paraoxonase, Malondialdehyde, and Lipoprotein Levels in Patients with Asymptomatic Cholelithiasis 
Background/Aim:
To compare lipoprotein and malondialdehyde levels and paraoxonase-1 activity between subjects with asymptomatic cholelithiasis and controls.
Patients and Methods:
Eighty subjects with asymptomatic cholelithiasis (55 women, 25 men, mean age: 51, SD 14 years) and 40 control subjects without cholelithiasis (25 women, 25 men, mean age: 51, SD 12 years) were enrolled to the study. Serum paraoxonase activity, lipoproteins, and malondialdehyde were measured.
Results:
In the cholelithiasis group, serum total cholesterol, low-density lipoprotein cholesterol, and malondialdehyde were significantly higher and high-density lipoprotein cholesterol (HDL-C) and paraoxonase-1 were significantly lower than the controls. In cholelithiasis patients with serum glucose level > 100 mg/dL, body mass index, serum total cholesterol, triglyceride (TG), and malondialdehyde levels were significantly higher than cholelithiasis patients with serum glucose level < 100 mg/dL. Paraoxonase-1 activity was significantly lower in patients with serum glucose level > 100 mg/dL. In cholelithiasis patients with TG > 150 mg/dL, mean age, body mass index, glucose, total cholesterol, and malondialdehyde were significantly higher than in cholelithiasis patients with TG < 150 mg/dL. In cholelithiasis subgroup with TG > 150 mg/dL, HDL-C level and paraoxonase-1 activity were lower than in the cholelithiasis subgroup with TG < 150 mg/dL. All of the above comparisons were statistically significant (P < 0.05).
Conclusions:
Patients with asymptomatic cholelithiasis have evidence of increased lipid peroxidation and decreased antioxidant capacity. Patients with asymptomatic cholelithiasis with components of the metabolic syndrome have more lipid peroxidation and less antioxidant capacity than patients with asymptomatic cholelithiasis but without the components of the metabolic syndrome.
doi:10.4103/1319-3767.126325
PMCID: PMC3952424  PMID: 24496161
Cholelithiasis; lipoproteins; malondialdehyde; paraoxonase
14.  Oral Conditions Associated with Hepatitis C Virus Infection 
Hepatitis C virus (HCV) infection in more than 170 million chronically infected patients with no developed preventive vaccine is a globally important issue. In addition to expected hepatic manifestations, a number of extrahepatic manifestations, such as mixed cryoglobulinemia, glomerulonephritis, polyarteritis nodosa, rashes, renal disease, neuropathy, and lymphoma, have been reported following HCV infection, which are believed to be influenced by the virus or the host immune response. HCV combination therapy with pegylated interferon and ribavirin might be associated with side effects as well. The association of HCV with special oral conditions has also been reported recurrently; the mechanism of most of which remains unclear. This article reviews the association of HCV infection with some of the oral conditions such as oral health, Sjogren's syndrome, lichen planus and oral cancer.
doi:10.4103/1319-3767.121032
PMCID: PMC3958971  PMID: 24195977
Hepatitis C; lichen planus; oral cancer; oral diseases; oral health; salivary gland; Sjogren's syndrome
15.  Correlation Between Hepatitis B Surface Antigen Titers and HBV DNA Levels 
Background/Aim:
To assess the correlation between serum HBsAg titers and hepatitis B virus (HBV) DNA levels in patients with hepatitis B envelop antigen-negative (HBeAg −ve) HBV genotype-D (HBV/D) infection.
Patients and Methods:
A total of 106 treatment- naïve, HBeAg −ve HBV/D patients were included; 78 in the inactive carrier (IC) state and 28 in the active hepatitis (AH) stage. HBV DNA load and HBsAg titers were tested using TaqMan real-time polymerase chain reaction (PCR) and automated chemiluminescent microparticle immunoassay, respectively.
Results:
The median (range) log10 HBsAg titer was significantly lower in the IC group compared with AH group, 3.09 (−1 to –4.4) versus 3.68 (−0.77 to 5.09) IU/mL, respectively; P < 0.001. The suggested cutoff value of HBsAg titer to differentiate between the two groups was 3.79 log10 IU/mL. In addition, there was a significant positive correlation between HBsAg and HBV DNA levels in the whole cohort, AH, and IC groups (r = 0.6, P < 0.0001; r = 0.591, P = 0.001; and r = 0.243, P = 0.032, respectively).
Conclusion:
Serum HBsAg titers may correlate with HBV DNA in treatment-naïve HBeAg –ve HBV/D patients, and supports the use of HBsAg levels in clinical practice as a predictor of serum HBV DNA levels.
doi:10.4103/1319-3767.121035
PMCID: PMC3958972  PMID: 24195978
Genotype D; HBV DNA; HBeAg negative; inactive carrier; quantitative HBsAg; Saudi Arabia
16.  Clinicopathologic Features of Gastric Cancer in Young Patients 
Background/Aim:
Gastric cancer (GC) is considered to be a disease of elderly patients. It has been suggested that GC in young adults has more aggressive clinical and pathologic features than in adults. In this study we aimed to evaluate clinical and pathologic features of GC under age 40 years.
Patients and Methods:
Patients included in this study were those treated and followed up for GC under age 40 years in Ankara Numune Education and Research Hospital from 2002 to 2011.
Results:
Clinical and pathologic features of 82 patients have been evaluated retrospectively. Of the patients 44 were male (54%) and 38 were (46%) female, and the median age was 35 years (min-max: 18-40 years). The tumor was grade 3 in 77% of the patients, 79% had diffuse type tumor, 64% had lymphovascular invasion, and 76% had perineural invasion. Forty-seven patients (57%) were metastatic at the time of diagnosis. The median follow up was 9 (1-101) months. The median overall survival (OS) was 9 months in metastatic patients and 8-year OS was 64% in nonmetastatic patients.
Conclusions:
We observed that young GC patients had more aggressive histopathologic features and more than half was metastatic at the time of diagnosis. We need more studies comparing young and elderly patients to confirm that young patients had more aggressive disease.
doi:10.4103/1319-3767.120876
PMCID: PMC3958973  PMID: 24195979
Gastric cancer; prognosis; young
17.  Study of Non–organ-specific Antibodies in Children with Genotype 4 Chronic Hepatitis C 
Background/Aim:
Adult studies established a relationship between hepatitis C virus (HCV) infection and the presence of non–organ-specific antibodies (NOSAs). Most studies were carried out on genotypes 1 and 2. Only a few studies addressed that issue in pediatrics. No studies have been carried out on autoimmunity and genotype 4 in children. We aim to investigate NOSAs in 80 Egyptian children with chronic HCV infection along with studying the underlying genotype of HCV, and correlating autoimmunity with the epidemiological, clinical, biochemical, and virological features.
Materials and Methods:
HCV-RNA was assayed by the polymerase chain reaction and viral genotypes were determined. NOSAs were measured and liver biopsies were taken for histopathological examination.
Results:
Genotype4 was the only detected genotype in the included 80 patients. Anti-smooth muscle antibodies (ASMA) were the only detected antibodies in 32 (40%) patients, always with V specificity (vessels only) at titers ranging from 1:20 and 1:160. Anti-nuclear antibodies (ANA) and liver–kidney microsomal antibodies-1 (LKMA-1) were not detected in any of our patients. Epidemiologic and clinical features did not significantly differ between autoantibody-positive and -negative patients. Among biochemical features, significantly high levels of total bilirubin, albumin, immunoglobulins, alkaline phosphatase, and gamma-glutamyl transpeptidase were found in the antibody-positive group.
Conclusion:
Genotype 4 HCV is the prevailing genotype in Egyptian children with chronic HCV infection. A consistent proportion of these children with chronic HCV infection circulate non–organ-specific autoantibodies. The prevalence of ASMA and the absence of ANA and LKMA-1 might be related to the unique situation in Egypt with unique prevalence of genotype 4. More studies are warranted on larger pediatric population to validate these findings.
doi:10.4103/1319-3767.121038
PMCID: PMC3958974  PMID: 24195980
Children; Egypt; genotype 4; hepatitis C; non-organ-specific antibodies
18.  Postoperative Peritonitis Without An Underlying Digestive Fistula After Complete Cytoreductive Surgery Plus HIPEC 
Background/Aim:
Peritoneal carcinomatosis (PC) is a pernicious event associated with a dismal prognosis. Complete cytoreductive surgery (CCRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is able to yield an important survival benefit but at the price of a risky procedure inducing potentially severe complications. Postoperative peritonitis after abdominal surgery occurs mostly when the digestive lumen and the peritoneum communicate but in rare situation, no underlying digestive fistula can be found. The aim of this study was to report this situation after CCRS plus HIPEC, which has not been described yet and for which the treatment is not yet well defined.
Patients and Methods:
Between 1994 and 2012, 607 patients underwent CCRS plus HIPEC in our tertiary care center and were retrospectively analyzed.
Results:
Among 52 patients (9%) reoperated for postoperative peritonitis, no digestive fistula was found in seven (1%). All had a malignant peritoneal pseudomyxoma with an extensive disease (median Peritoneal Cancer Index: 27). The median interval between surgery and reoperation was 8 days [range: 3-25]. Postoperative mortality was 14%. Five different bacteriological species were identified in intraoperative samples, most frequently Escherichia coli (71%). The infection was monobacterial in 71%, with multidrug resistant germs in 78%.
Conclusions:
Postoperative peritonitis without underlying fistula after CCRS plus HIPEC is a rare entity probably related to bacterial translocation, which occurs in patients with extensive peritoneal disease requiring aggressive surgeries. The principles of treatment do not differ from that of other types of postoperative peritonitis.
doi:10.4103/1319-3767.121033
PMCID: PMC3958975  PMID: 24195981
Digestive fistula; hyperthermic intraperitoneal chemotherapy; peritoneal carcinomatosis; postoperative peritonitis; spontaneous bacterial peritonitis
19.  Clinical Predictors of Resectability of Pancreatic Adenocarcinoma 
Background/Aims:
Identifying patient-related factors as well as symptoms and signs that can predict pancreatic cancer at a resectable stage, which could be used in an attempt to identify patients at an early stage of pancreatic cancer that would be appropriate for surgical resection and those at an unresectable stage be sparred unnecessary surgery.
Materials and Methods:
A retrospective chart review was conducted at a major tertiary care, university hospital in Riyadh, Saudi Arabia. The study population included individuals who underwent a computed tomography and a pancreatic mass was reported as well as the endoscopic reporting database of endoscopic procedures where the indication was a pancreatic mass, between April 1996 and April 2012. Any patient with a histologically confirmed diagnosis of adenocarcinoma of the pancreas was included in the analysis. We included patients’ demographic information (age, gender), height, weight, body mass index, historical data (smoking, comorbidities), symptoms (abdominal pain and its duration, anorexia and its duration, weight loss and its amount, and over what duration, vomiting, abdominal distention, itching and its duration, change in bowel movements, change in urine color), jaundice and its duration. Other variables were also collected including laboratory values, location of the mass, the investigation undertaken, and the stage of the tumor.
Results:
A total of 61 patients were included, the mean age was 61.2 ± 1.51 years, 25 (41%) were females. The tumors were located in the head (83.6%), body (10.9%), tail (1.8%), and in multiple locations (3.6%) of the pancreas. Half of the patients (50%) had Stage IV, 16.7% stages IIB and III, and only 8.3% were stages IB and IIA. On univariable analysis a lower hemoglobin level predicted resectability odds ratio 0.65 (95% confidence interval, 0.42-0.98), whereas on multivariable regression none of the variables included in the model could predict resectability of pancreatic cancer. A CA 19-9 cutoff level of 166 ng/mL had a sensitivity of 89%, specificity of 75%, positive likelihood ratio of 3.6, and a negative likelihood ratio of 0.15 for resectability of pancreatic adenocarcinoma.
Conclusion:
This study describes the clinical characteristics of patients with pancreatic adenocarcinoma in Saudi Arabia. None of the clinical or laboratory variables that were included in our study could independently predict resectability of pancreatic adenocarcinoma. Further studies are warranted to validate these results.
doi:10.4103/1319-3767.121036
PMCID: PMC3958976  PMID: 24195982
Clinical predictors; pancreatic adenocarcinoma; resectability
20.  Vanishing Bile Duct Syndrome in a Hodgkin's Lymphoma Patient with Fatal Outcome Despite Lymphoma Remission 
Vanishing bile duct syndrome (VBDS) is a condition resulting from severe bile duct injury, progressive destruction, and disappearance of intrahepatic bile ducts (ductopenia) leading to cholestasis, biliary cirrhosis, and liver failure. VBDS can be associated with a variety of disorders, including Hodgkin's lymphoma (HL). We describe a 33-year-old male patient who presented with lymphadenopathy and jaundice, and was diagnosed to have HL. Serum bilirubin worsened progressively despite chemotherapy, with a cholestatic pattern of liver enzymes. Diagnosis of VBDS was established on liver biopsy. Although remission from HL was achieved, the patient died of liver failure. Presence of jaundice in HL patients should raise the possibility of VBDS. This report discusses the difficulties of delivering chemotherapy in patients with liver dysfunction. HL-associated VBDS carries a high mortality but lymphoma remission can be achieved in some patients. Therefore, liver transplantation should be considered early in these patients.
doi:10.4103/1319-3767.121037
PMCID: PMC3958977  PMID: 24195983
Chemotherapy; Hodgkin's lymphoma; vanishing bile duct syndrome
22.  State-of-the-Art Management of Acute Bleeding Peptic Ulcer Disease 
The management of patients with non variceal upper gastrointestinal bleeding has evolved, as have its causes and prognosis, over the past 20 years. The addition of high-quality data coupled to the publication of authoritative national and international guidelines have helped define current-day standards of care. This review highlights the relevant clinical evidence and consensus recommendations that will hopefully result in promoting the effective dissemination and knowledge translation of important information in the management of patients afflicted with this common entity.
doi:10.4103/1319-3767.118116
PMCID: PMC3793470  PMID: 24045592
Clips; endoscopic hemostasis; endoscopy; hemostatic powders; injection; non variceal; prokinetic drugs; proton pump inhibitors; thermal coagulation; transfusion; upper gastrointestinal bleeding
23.  Administration of Erythromycin Before Endoscopy in Upper Gastrointestinal Bleeding: A Meta-analysis of Randomized Controlled Trials 
Background/Aim:
Erythromycin infusion before endoscopy in upper gastrointestinal bleeding (UGIB) has been hypothesized to aid in visualization and reduce the need for second-look endoscopy; however, the results have been controversial. To evaluate further, we performed a meta-analysis comparing the efficacy of erythromycin infusion before endoscopy in acute UGIB.
Methods:
Multiple databases were searched (March 2013). Only randomized controlled trials were included in the analysis. A meta-analysis for the effect of erythromycin or no erythromycin before endoscopy in UGIB were analyzed by calculating pooled estimates of primary (visualization of gastric mucosa and need for second endoscopy) and secondary (units of blood transfused, length of hospital stay, duration of the procedure) outcomes. Statistical analysis was performed using RevMan 5.1 (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration).
Results:
Six studies (N = 558) met the inclusion criteria. Erythromycin infusion before endoscopy in UGIB demonstrated a statistically significant improvement in visualization of the gastric mucosa [odds ratio (OR) 3.43; 95% confidence interval (CI): 1.81 to 6.50, P < 0.01] compared with no erythromycin. In addition, erythromycin infusion before endoscopy resulted in a statistically significant decrease in the need for a second endoscopy (OR 0.47; 95% CI: 0.26 to 0.83, P = 0.01), units of blood transfused (WMD − 0.41; 95% CI: −0.82 to −0.01, P = 0.04), and the duration of hospital stay (WMD − 1.51; 95% CI: −2.45 to −0.56, P < 0.01).
Conclusions:
Erythromycin infusion before endoscopy in patients with UGIB significantly improves visualization of gastric mucosa while decreasing the need for a second endoscopy, units of blood transfused, and duration of hospital stay.
doi:10.4103/1319-3767.118120
PMCID: PMC3793471  PMID: 24045593
Erythromycin; endoscopy; meta-analysis; upper gastrointestinal bleeding
24.  Comparison of the Virulence Markers of Helicobacter Pylori and their Associated Diseases in Patients from Pakistan and Afghanistan 
Background/Aim:
Helicobacter pylori is a Gram-negative bacteria, which is associated with development of gastroduodenal diseases. The prevalence of H. pylori and the virulence markers cytotoxin-associated gene A and E (cagA, cagE) and vacuolating-associated cytotoxin gene (vacA) alleles varies in different parts of the world. H. pylori virulence markers cagA, cagE, and vacA alleles in local and Afghan nationals with H. pylori-associated gastroduodenal diseases were studied.
Patients and Methods:
Two hundred and ten patients with upper gastrointestinal symptoms and positive for H. pylori by the urease test and histology were included. One hundred and nineteen were local nationals and 91 were Afghans. The cagA, cagE, and vacA allelic status was determined by polymerase chain reaction.
Results:
The nonulcer dyspepsia (NUD) was common in the Afghan patients (P = 0.025). In Afghan H. pylori strains, cagA was positive in 14 (82%) with gastric carcinoma (GC) compared with 29 (45%) with NUD (P = 0.006), whereas cagE was positive in 11 (65%) with GC and 4 (67%) with duodenal ulcer (DU) compared with 12 (18%) with NUD (P < 0.001 and 0.021, respectively). The vacA s1a/b1 was positive in 10 (59%) of GC compared with 20 (31%) in NUD (P = 0.033). In Pakistani strains, cagE was positive in 12 (60%) with GC, 7 (58%) with GU, 12 (60%) with DU compared with 11 (16%) with NUD (P < 0.001, 0.004, and < 0.001, respectively). In Pakistani strains, cagA/s1a/m1 was 39 (33%) compared with Afghans in 17 (19%) (P = 0.022). Moderate to severe mucosal inflammation was present in 51 (43%) Pakistani patients compared with 26 (28%) (P = 0.033) in Afghans. It was also associated with grade 1 lymphoid aggregate development in Pakistani patients 67 (56%) compared with 36 (40%) (P = 0.016) in Afghans.
Conclusion:
Distribution of H. pylori virulence marker cagE with DU was similar in Afghan and Pakistan H. pylori strains. Chronic active inflammation was significantly associated with Pakistani H. pylori strains.
doi:10.4103/1319-3767.118123
PMCID: PMC3793472  PMID: 24045594
cagA; cagE; gastritis; gastric carcinoma; Helicobacter pylori
25.  Appropriateness and Diagnostic Yield of Upper Gastrointestinal Endoscopy in an Open-Access Endoscopy System 
Background/Aim:
Open access endoscopy (OAE) decreases the waiting time for patients and clinical burden to gastroenterologist; however, the appropriateness of referrals for endoscopy and thus the diagnostic yield of these endoscopies has become an important issue. The aim of this study was to determine the appropriateness of upper gastrointestinal (GI) endoscopy requests in an OAE system.
Patients and Methods:
A retrospective chart review of all consecutive patients who underwent an upper gastroscopy in the year 2008 was performed and was defined as appropriate or inappropriate according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines. Endoscopic findings were recorded and classified as positive or negative. Referrals were categorized as being from a gastroenterologist, internist, surgeon, primary care physicians or others, and on an inpatient or out-patient basis.
Results:
A total of 505 consecutive patients were included. The mean age was 45.3 (standard deviation 18.1), 259 (51%) of them were males. 31% of the referrals were thought to be inappropriate. Referrals from primary care physicians were inappropriate in 47% of patients while only 19.5% of gastroenterologists referrals were considered inappropriate. Nearly, 37.8% of the out-patient referrals were inappropriate compared to only 7.8% for inpatients. Abnormal findings were found in 78.5% and 78% of patients referred by gastroenterologists and surgeons respectively while in those referred by primary care physicians it was (49.7%). Inpatients referred for endoscopy had abnormal findings in (81.7%) while in out-patients it was (66.6%). The most common appropriate indications in order of frequency were “upper abdominal distress that persisted despite an appropriate trial of therapy” (78.9%), “persistent vomiting of unknown cause” (19.2%), upper GI bleeding or unexplained iron deficiency anemia (7.6%). The sensitivity and specificity of the ASGE guidelines in our study population was 70.3% and 35% respectively.
Conclusion:
A large proportion of patients referred for endoscopy through our open-access endoscopy unit are considered inappropriate, with significant differences among specialties. These results suggest that if proper education of practitioners was implemented, a better utilization would be expected.
doi:10.4103/1319-3767.118128
PMCID: PMC3793473  PMID: 24045595
Appropriateness of gastroscopy; gastroscopy; open access endoscopy; Saudi Arabia

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