Epidemiology and outcome of Crohn's disease in a teaching hospital in Riyadh

AIM: To know the epidemiology and outcome of Crohn's disease at King Khalid University Hospital, Riyadh, Saudi Arabia and to compare the results from other world institutions.METHODS: A retrospective analysis of patients seen for 20 years (between 1983 and 2002). Individual case records were reviewed with regard to history, clinical, findings from colonoscopy, biopsies, small bowel enema, computerized tomography scan, treatment and outcome.RESULTS: Seventy-seven patients with Crohn's disease were revisited, 13% presented the disease in the first 10 years and 87% over the last 10 years. Thirty-three patients (42.9%) were males and 44 (57.1%) were females. Age ranged from 11-70 years (mean of 25.3+11.3 years). Ninety-two (92%) were Saudi. The mean duration of symptoms was 26+34.7 mo. The mean annual incidence of the disease over the first 10 years was 0.32:100 000 and 1.66:100 000 over the last 10 years with a total mean annual incidence of 0.94:100 000 over the last 20 years. The chief clinical features included abdominal pain, diarrhea, weight loss,anorexia, rectal bleeding and palpable mass. Colonoscopic findings were abnormal in 58 patients (76%) showing mostly ulcerations and inflammation of the colon. Eighty nine percent of patients showed nonspecific inflammation with chronic inflammatory cells and half of these patients revealed the presence of granulomas and granulations on bowel biopsies. Similarly, 69 (89%) of small bowel enema results revealed ulcerations (49%), narrowing of the bowel lumen (42%), mucosal thickening (35%) and cobblestone appearance (35%). CT scan showed abnormality in 68 (88%) of patients with features of thickened loops (66%) and lymphadenopathy (37%). Seventy-eight percent of patients had small and large bowel disease, 16% had small bowel involvement and only 6% had colitis alone. Of the total 55 (71%) patients treated with steroids at some point in their disease history, a satisfactory response to therapy was seen in 28 patients (51%) while 27 (49%) showed recurrences of the condition with mild to moderate symptoms of abdominal pain and diarrhea most of which were due to poor compliance to medication. Seven patients (33%) remained with active Crohn's disease. Nine (12%) patients underwent surgery with resections of some parts of bowel, 2 (2.5%) had steroid side effects, 6 (8%) with perianal Crohn's disease and five (6.5%) with fistulae.CONCLUSION: The epidemiological characteristics of Crohn's disease among Saudi patients are comparable to those reported from other parts of the world. However the incidence of Crohn's disease in our hospital increased over the last 10 years. The anatomic distribution of the disease is different from other world institutions with less isolated colonic affection.

Intestinal carriage of methicillin resistant Staphylococcus aureus and extended-spectrum β-Lactamase-producing Enterobacteriacae in hospitalized and nonhospitalized patients and their clinical implications

Objective:To determine the clinical implication of and intestinal carriage with methicillin resistant Staphylococcus aureus(MRSA) and extended spectrumβ-lactamase(ESBL)-producing Enterobacteriacae.Methods: A total of 180 stool specimens were screened for MRSA and ESBL-producing enterobacteria.Identification of ESBL- producing Enterobacteriacae was done by MicroScan Walk Away 96 system(Dade Behring Inc.,West Sacramento,CA 95691,USA ) and confirmation by double-disc synergy test.MRSA was identified by disc diffusion using 30μg cefoxitin disc and the MicroScan.Results:The rate of fecal MRSA carriage was 7.8% (14/180),35.7%(5 /14) were recovered from surgical wards.Three patients(21,4%) had MRSA recovered from other body sites,and 2(14.2%) had in addition ESBL -producing Escherichia coli(E.coli) and Klebsiella pneumoniae(K.pneumoniae) respectively.Four(28.5%) patients with MRSA fical carriage died. MRSA fecal carriage was recovered from both inpatients and outpatients.Four(2.2%) cases carried ESBL-producing Enterobacteriacae in feces.Three(75%) were from intensive care unit(ICU).One patient had both ESBL-producing E.coli and K.pneumoniae from stool as well as E.coli from tracheal aspirate.Two ICU patients with fecal ESBL died.Conclusion:Fecal screening for MRSA and ESBL of all patients at high risk admitted to different hospital wards and ICUs and implementing infection control measures were recommended.

Tuberculosis: Awareness among Students in a Saudi University

Background: Knowledge plays a vital role in influencing the behavior and practices of individuals. Tuberculosis (TB) is a major public health problem. Our objective is to identify the extent of awareness about TB among King Saud University students, and to compare knowledge about tuberculosis amongst different University tracks. Methods: This study was conducted using a cross-sectional approach including 530 students in three different academic tracks: Health, Scientific, and Humanitarian tracks. For data collection, a structured questionnaire was developed through revision of the literature which contained three different parts;demographic data of subjects, knowledge about TB and attitude toward TB. Results: The established scoring system revealed a poor grade of knowledge at 51.4%. Tuberculosis knowledge was significantly higher amongst the track of Health colleges (46.7% compared with 27.2% for the track of Science and 26% for the track of Humanitarian studies). However, some of the issues were answered fittingly in higher magnitude by the two other non-health tracks;there was no significant difference in gender-specific awareness level (48% for both). Conclusion: Although the Health track has better knowledge in general (46.7%), the level of awareness of Tuberculosis is poor among King Saud University students. Moreover, the level of awareness differs among the three tracks, which are health, humanitarian, and science. The health track showed the highest level of awareness.

Severe acute pancreatitis: Pathogenetic aspects and prognostic factors

Approximately 20% of patients with acute pancreatitis develop a severe disease associated with complications and high risk of mortality. The purpose of this study is to review pathogenesis and prognostic factors of severe acute pancreatitis （SAP）. An extensive medline search was undertaken with focusing on pathogenesis, complications and prognostic evaluation of SAP. Cytokines and other inflammatory markers play a major role in the pathogenesis and course of SAP and can be used as prognostic markers in its early phase. Other markers such as simple prognostic scores have been found to be as e^ective as multifactorial scoring systems （MFSS） at 48 h with the advantage of simplicity, efficacy, low cost, accuracy and early prediction of SAP. Recently, several laboratory markers including hematocrit, blood urea nitrogen （BUN）, creatinine, matrix metalloproteinase-9 （MMP-9） and serum amyloid A （SAA） have been used as early predictors of severity within the first 24 h. The last few years have witnessed a tremendous progress in understanding the pathogenesis and predicting the outcome of SAP. In this review we classified the prognostic markers into predictors of severity, pancreatic necrosis （PN）, infected PN （IPN） and mortality.

Primary gastric lymphoma

AIM:The purpose of this review is to describe the various aspects of primary gastric lymphoma and the treatment options currently available. METHODS:After a systematic search of Pubmed,Medscape and MDconsult,we reviewed and retrieved literature regarding gastric lymphoma. RESULTS:Primary gastric lymphoma is rare however,the incidence of this malignancy is increasing.Chronic gastritis secondary to Helicobacter pylori (H pylori) infection has been considered a major predisposing factor for MALT lymphoma. Immune histochemical marker studies and molecular biology utilizing polymerase chain reaction have facilitated appropriate diagnosis and abolished the need for diagnostic surgical resection.Advances in imaging techniques including Magnetic Resonance Imaging (MRI) and Endoscopic Ultrasonography (EUS) have helped evaluation of tumor extension and invasion. The clinical course and prognosis of this disease is dependent on histopathological sub-type and stage at the time of diagnosis.Controversy remains regarding the best treatment for early stages of this disease.Chemotherapy,surgery and combination have been studied and shared almost comparable results with survival rate of 70-90%.However,chemotherapy possesses the advantage of preserving gastric anatomy. Radiotherapy alone has been tried and showed good results. Stage IIIE,IVE disease treatment is solely by chemotherapy and surgical resection has been a remote consideration. CONCLUSION:We conclude that methods of diagnosis and staging of the primary gastric lymphoma have dramatically improved.The modalities of treatment are many and probably chemotherapy is superior because of high success rate, preservation of stomach and tolerable complications.

Complications and survival in patients undergoing colonic stenting for malignant obstruction

AIM:To investigate whether predicting patients that might be at a higher risk for complications might serve to improve the selection of patients undergoing colonic stenting.METHODS:A retrospective review of consecutive patients who underwent an attempted self-expandable metal stent(SEMS)insertion for malignant colonic obstruction between November 2006 and March 2013.All patients were either referred for preoperative colonic decompression with the intent of a single surgical procedure,or for palliation of the malignant colorectal obstruction for unresectable cancer.Fisher’s test orχ2test was performed on categorical variables,and the t test for continuous variables.Univariable and multivariable logistic regression were used to examine the association between independent variables and the presence of complications from SEMS insertion.RESULTS:SEMS insertion was attempted in 73 patients.Males comprised 55.71%and the mean age was 67.41±12.41 years.Of these,65.15%underwent subsequent surgery,while 34.85%received SEMS as palliation for advanced disease.Extracolonic tumors were only4.76%.The majority of patients had stageⅣdisease(63.83%),while the remainder had stageⅢ(36.17%).SEMS were successfully inserted in 93.85%(95%CI:87.85%-99.85%).Perforations occurred in 4.10%,SEMS migration in 8.21%,and stent re-occlusion from ingrowth occurred in 2.74%of patients.The mean duration of follow up for the patients was 13.52±17.48 mo(range 0-73 mo).None of the variables:age,sex,time between the onset of symptoms to SEMS insertion,time between SEMS insertion and surgery,length of the stenosis,location of the stenosis,albumin level,or receiving neoadjuvant chemotherapy,could predict the development of complications from either SEMS insertion nor prolonged survival.CONCLUSION:None of the variables could predict the development of complications or survival.Further studies are required to identify patients who would benefit the most from SEMS.

Spices, herbal xenobiotics and the stomach: Friends or foes?

Spices and herbal remedies have been used since ancient times to treat a variety of disorders. It has been experimentally demonstrated that spices, herbs, and their extracts possess antimicrobial, anti-inflammatory, antirheumatic, lipid-lowering, hepatoprotective, nephroprotective, antimutagenic and anticancer activities, besides their gastroprotective and anti-ulcer activities. Despite a number of reports on the toxicity of herbs and spices, they are generally accepted as safer alternatives to conventional therapy against gastric ulcers. To this end, it is also believed, that excessive consumption of spices may favor the pathogenesis of gastric and duodenal ulcer and some studies have substantiated this common perception. Based on various in vivo experiments and clinical studies, on the effects of spices and herbs on gastric ulcers, it has indeed been shown that certain spices do possess remarkable anti-ulcer properties mediated by antisecretory, cytoprotective, antioxidant, and anti-Helicobacter pylori effects and mechanisms regulated by nitric oxide, prostaglandins, non-protein sulfhydryl molecules and epidermal growth factor expression. Accordingly, their consumption may attenuate and help prevent peptic ulcer disease. In the present review, the beneficial effects of spices and herbal nutritive components on the gastric mucosa are discussed against the paradigm of their deleterious potential.

Resolution of tuberculous biliary stricture after medical therapy

Tuberculosis （TB） is a very rare cause of biliary stricture that is difficult to diagnose and usually requires surgical intervention in order to rule out underlying malignant etiology. We report a 56-year-old man presented with jaundice, weight loss and poor appetite. Initial work up showed the dilated biliary system secondary to distal common bile duct stricture. Investigations to define the etiology of this stricture showed inconclusive brush cytology with absent abdominal masses and lymph nodes but enlarged mediastinal lymph nodes. Biopsy from these lymph nodes showed a non-caseating epitheliod granuloma with negative acid fast bacilli （AFB） stain. The patient had a dramatic response to empirical antituberculosis therapy. Six weeks later, culture from lymph nodes was positive for Mycobacteriurn tuberculosis. Three months later, follow-up cholangiogram showed complete resolution of the stricture with normalization of liver enzymes 6 mo after starting anti-tuberculosis therapy. Treatment was continued for 12 mo and the patient had a normal life with normal liver enzymes and regression of the mediastinal lymph nodes at the time when he was reported in this paper. Although 16 cases of tuberculous biliary stricture are available in the English literature, up to our knowledge, this is the second published report of tuberculous biliary stricture, which resolved completely after medical therapy alone and the second reported case from the Middle East. This report emphasizes the importance of keeping TB as a possibility of biliary stricture in this part of the world.

Performance of American Society for Gastrointestinal Endoscopy guidelines for dyspepsia in Saudi population: Prospective observational study

AIM: To evaluate adherence of primary care physicians(PCPs) to international guidelines when referring patients for upper-gastrointestinal endoscopy(UGE), evaluate the importance of alarm symptoms and the performance of the American Society for Gastrointestinal Endoscopy(ASGE) guidelines in a Saudi population.METHODS: A prospective, observational cross-sectional study on dyspeptic patients undergoing UGE who were referred by PCPs over a 4 mo period. Refer-rals were classified as appropriate or inappropriate according to adherence to ASGE guidelines.RESULTS: Total of 221 dyspeptic patients was enrolled; 161 patients met our inclusion criteria. Mean age was 40.3 years(SD ± 18.1). Females comprised 70.1%. Alarm symptoms included low hemoglobin level(39%), weight loss(18%), vomiting(16%), loss of appetite(16%), difficulty swallowing(3%), and gastrointestinal bleeding(3%). Abnormal endoscopy findings included gastritis(52%), duodenitis(10%), hiatus hernia(7.8%), features suggestive of celiac disease(6.5%), ulcers(3.9%), malignancy(2.6%) and gastroesophageal reflux disease(GERD: 17%). Among patients who underwent UGE, 63% met ASGE guidelines, and 50% had abnormal endoscopic findings. Endoscopy was not indicated in remaining 37% of patients. Among the latter group, endoscopy was normal in 54% of patients. There was no difference in proportion of abnormal endoscopic findings between two groups(P = 0.639).CONCLUSION: Dyspeptic patients had a low prevalence of important endoscopic lesions, and none of the alarm symptoms could significantly predict abnormalendoscopic findings.

Sedated vs unsedated colonoscopy:A prospective study

AIM:To compare sedated to unsedated colonoscopy in terms of duration,pain and the patient’s willingness to repeat the procedure.METHODS:Consecutive patients who underwent colonoscopies over a 2-year period were invited to participate.All patients who were to undergo our endoscopy unit were offered sedation with standard intravenous sedatives and analgesics,or an unsedated colonoscopy was attempted.Demographic details were recorded.The patient anxiety level prior to the procedure,time to reach the cecum,total discharge time,patient and endoscopist pain assessments,satisfaction after the examination and the patient’s willingness to return for the same procedure in the future were recorded.RESULTS:Among the 403 observed patients,more males were observed in the unsedated group(66.2%vs 55.2%,P=0.04).Additionally,the unsedated group patients were less anxious prior to the procedure(5.1vs 6.0,P<0.01).The colonoscopy completion rates were comparable between the 2 groups(85.9%vs84.2%,P=0.66).The time to reach the cecum was also comparable(12.2 min vs 11.8 min);however,the total discharge times were shorter in the unsedated group(20.7 min vs 83.0 min,P<0.01).Moreover,the average patient pain score(3.4 vs 5.7,P<0.01)was lower in the sedated group,while the satisfaction score(8.8 vs 7.8,P<0.01)was significantly higher.There was no significant difference,however,between the groups in terms of willingness to repeat the procedure if another was required in the future(83.3%vs 77.3%,P=0.17).CONCLUSION:Unsedated colonoscopy is feasible in willing patients.The option saves the endoscopy units up to one hour per patient and does not affect the patient willingness to return to the same physician again for additional colonoscopies if a repeated procedure is needed.

Fatal aortoesophageal fistula bleeding after stenting for a leak post sleeve gastrectomy

Bariatric surgeries have been used in an effort to curtail the obesity epidemic. The type of surgery used has changed over time, with sleeve gastrectomies being one of the preferred options. This has been associated with some complications, including staple line leaks. We report a 43-year old female who had undergone a laparoscopic sleeve gastrectomy that was complicated by a proximal gastric pouch leak at the gastroesophageal junction. We used self-expandable stents(SEMS) in the management of the leak. Seven weeks after the insertion of the initial SEMS, the patient presented with a massive gastrointestinal bleed that could not be localized due to profuse bleeding. The patient underwenta computerized tomography angiogram and then an angiogram that could not localize the site of the bleed. An emergency laparotomy was performed and identified the source of bleeding to be an aortoesophageal fistula. A graft of the diseased area was attempted but the patient unfortunately did not survive the procedure. An aortoesophageal fistula after an esophageal SEMS insertion for a benign disease has rarely been reported and only in cases where there was a thoracic neoplasm, thoracic aortic aneurism, endovascular stent repair, foreign body or esophageal surgery. To our knowledge, this is the first case that reports an aortoesophageal fistula as a result of a SEMS for the management of a gastric pouch leak after a laparoscopic sleeve gastrectomy.

Prevalence and clinical features of colonic diverticulosis in a Middle Eastern population

AIM: To determine the prevalence, location, associations and clinical features of colonic-diverticulosis and its role as a cause of lower-gastroenterology-bleeding. METHODS: We retrospectively reviewed the medical records of 3649 consecutive patients who under-went a colonoscopy for all indications between 2007 and 2011 at King Khalid University Hospital, Riyadh, Saudi Arabia. The demographic data were collected retrospectively through the hospital's information system, electronic file system, endoscopic e-reports, and manual review of the files by two research assistants. The demographic information included the age, sex, comorbidities and indication for the colonoscopy. The association among colonic polyps, comorbidities and diverticular disease was also measured.RESULTS: A total of 270 patients out of 3649 were diagnosed with colonic diverticulosis, with a prevalence of 7.4%. The mean age was 60.82 years ± 0.833, (range 12-110). Females comprised 38.89% (95%CI: 33-44.7) of the study population. The major symp-toms were rectal bleeding in 33.6%, abdominal pain in 19.3%, constipation in 12.8% and anemia in 6%. Diverticula were predominantly left-sided (sigmoid and descending colon) in 62%, right-sided in 13% and in multiple locations in 25%. There was an association between the presence of diverticulosis and adenomatous polyps (Pvalue < 0.001), hypertension (P-value < 0.0001) and diabetes mellitus (P-value < 0.0016). Diverticular disease was the second most common cause of lower gastrointestinal bleeding, in 33.6% (95%CI: 27.7-39.4), after internal hemor-rhoids, in 44.6% (95%CI: 40.3-48.9). On multivariable logistic regression, hypertension (OR = 2.30; 95%CI: 1.29-4.10), rectal bleeding (OR = 2.57; 95%CI: 1.50-4.38), and per year increment in age (OR = 1.05; 95%CI: 1.03-1.07) were associated with diverticulosis but not with bleeding diverticular disease. Limitations: A small proportion of the patients included had colo-noscopies performed as a screening test.CONCLUSION: Colonic-diverticulosis was found to have a low prevalence, be predominantly left-sided and associated with adenomatous-polyps. Age, hypertension and rectal bleeding predict the presence of diverticular disease.

Resolution of an esophageal leak and posterior gastric wall necrosis with esophageal self-expandable metal stents

The use of weight reduction surgeries has increased over the years with a higher proportion of these surgeries being sleeve gastrectomies,this has been associated with some complications including staple line leaks.We report a 32-year-old male who had undergone a laparoscopic gastric band surgery and subsequently a laparoscopic sleeve gastrectomy,this was complicated by both an staple line leak at the gastroesophageal junction as well as a large(> 4 cm) posterior gastric wall defect due to gastric wall necrosis. We used two co-axially inserted self-expandable stents(SEMS) in the management of this patient,5 stents were used over repeated endoscopy sessions and 20 wk. Both defects had resolved without the need for surgical intervention.This is the first reported case were SEMS are used for both a staple line leak as well as a gastric wall defect.We also review the literature on the use of SEMS in the management of leaks post weight reduction surgeries.

Clinical epidemiology of ulcerative colitis in Arabs based on the Montréal classification

AIM:To determine the clinical,epidemiological and phenotypic characteristics of ulcerative colitis(UC)in Saudi Arabia by studying the largest cohort of Arab UC patients.METHODS:Data from UC patients attending gastroenterology clinics in four tertiary care centers in three cities between September 2009 and September 2013were entered into a validated web-based registry,inflammatory bowel disease information system(IBDIS).The IBDIS database covers numerous aspects of inflammatory bowel disease.Patient characteristics,disease phenotype and behavior,age at diagnosis,course of the disease,and extraintestinal manifestations were recorded.RESULTS:Among 394 UC patients,males comprised51.0%and females 49.0%.According to the Montréal classification of age,the major chunk of our patients belonged to the A2 category for age of diagnosis at17-40 years(68.4%),while 24.2%belonged to the A3category for age of diagnosis at>40 years.According to the same classification,a majority of patients had extensive UC(42.7%),35.3%had left-sided colitis and29.2%had only proctitis.Moreover,51.3%were in remission,16.6%had mild UC,23.4%had moderate UC and 8.6%had severe UC.Frequent relapse occurred in17.4%patients,infrequent relapse in 77%and 4.8%had chronic disease.A majority(85.2%)of patients was steroid responsive.With regard to extraintestinal manifestations,arthritis was present in 16.4%,osteopenia in 31.4%,osteoporosis in 17.1%and cutaneous involvement in 7.0%.CONCLUSION:The majority of UC cases were young people(17-40 years),with a male preponderance.While the disease course was found to be similar to that reported in Western countries,more similarities were found with Asian countries with regards to the extent of the disease and response to steroid therapy.

Sedation-risk-free colonoscopy for minimizing the burden of colorectal cancer screening

Unsedated colonoscopy is available worldwide,but is not a routine option in the United States(US).We conducted a literature review supplemented by our experience and expert commentaries to provide data to support the use of unsedated colonoscopy for colorectal cancer screening.Medline data from 1966 to 2009 were searched to identify relevant articles on the subject.Data were summarized and co-authors provided critiques as well as accounts of unsedated colonoscopy for screening and surveillance.Diagnostic colonoscopy was initially dev eloped as an unsedated procedure.Procedure-re lated discomfort led to wide adoption of sedation in the US,although unsedated colonoscopy remains the usual practice elsewhere.The increased use of colonoscopy for colorectal cancer screening in healthy,asymptomatic individuals suggests a reass-essment of the burden of sedation in colonoscopy for screening is appropriate in the US for lowering costs and minimizing complications for patients.A water method developed to minimize discomfort has shown promise to enhance outcomes of unsedated colonoscopy.The use of scheduled,unsedated colono scopy in the US appears to be feasible for colorectal cancer screening.Studies to assess its applicability in diverse practice settings deserve to be conducted and supported.

Seroprevalence of celiac disease among healthy adolescents in Saudi Arabia

AIM: To identify the seroprevalence of celiac disease among healthy Saudi adolescents. METHODS: Between December 2007 and January 2008, healthy students from the 10th to 12th grades were randomly selected from three regions in Saudi Arabia. These regions included the following: (1) Aseer region, with a student population of 25512; (2) Madinah, with a student population of 23852; and (3) Al-Qaseem, with a student population of 16067. Demographic data were recorded, and a venous blood sample (5-10 mL) was taken from each student. The blood samples were tested for immunoglobulin A and immunoglobulin G endomysial antibodies (EMA) by indirect immunofluorescence.RESULTS: In total, 1167 students (614 males and 553 females) from these three regions were randomly selected. The majority of the study population was classified as lower middle class (82.7%). There were 26 (2.2%) students who had a positive anti-EMA test, including 17 females (3.1%) and 9 males (1.5%). Al-Qaseem region had the highest celiac disease prevalence among the three studied regions in Saudi Arabia (3.1%). The prevalence by region was as follows: Aseer 2.1% (10/479), Madinah 1.8% (8/436), and Al-Qaseem 3.2% (8/252). The prevalence in Madinah was significantly lower than the prevalence in Aseer and Al-Qaseem (P=0.02). CONCLUSION: Our data suggest celiac disease prevalence might be one of the highest in the world. Further studies are needed to determine the real prevalence.

Rocket “Eruca sativa”:A salad herb with potential gastric anti-ulcer activity

AIM： To validate gastric anti-ulcer properties of Rocket ＂Eruca sativa＂ on experimentally-induced gastric secretion and ulceration in albino rats. METHODS： Gastric acid secretion studies were undertaken using pylorus-ligated rats. Gastric lesions in the rats were induced by noxious chemicals including ethanol, strong alkalis, indomethacin and hypothermic restraint stress. The levels of gastric wall mucus （GWM）, nonprotein sulfhydryls （NP-SH） and malondialdehyde （MDA） were also measured in the glandular stomach of rats following ethanol administration. The gastric tissue was also examined histologically. The extract was used in two doses （250 and 500 mg/kg body weight） in all experiments. RESULTS： In pylorus-ligated Shay rats, the ethanolic extract of Rocket ＂Eruca sativa L.＂ （EER） significantly and dose-dependently reduced the basal gastric acid secretion, titratable acidity and ruminal ulceration. Rocket extract significantly attenuated gastric ulceration induced by necrotizing agents （80% ethanol, 0.2 mol/L NaOH, 25% NaCl）, indomethacin and hypothermic restraint stress. The anti-ulcer effect was further confirmed histologically. On the other hand, the extract significantly replenished GWM and NP-SH levels, as well as the MDA level significantly reduced by extract pretreatment. CONCLUSION： Rocket extract possesses antisecretory, cytoprotective, and anti-ulcer activities against experimentally-induced gastric lesions. The anti-ulcer effect is possibly through prostaglandinmediated activity and/or through its anti-secretory and antioxidant properties.

Agmatine induces gastric protection against ischemic injury by reducing vascular permeability in rats

AIM:To investigate the effect of administration of agmatine(AGM) on gastric protection against ischemia reperfusion(I/R) injury.METHODS:Three groups of rats(6/group);sham,gastric I/R injury,and gastric I/R + AGM(100 mg/kg,i.p.given 15 min prior to gastric ischemia) were recruited.Gastric injury was conducted by ligating celiac artery for 30 min and reperfusion for another 30 min.Gastric tissues were histologically studied and immunostained with angiopoietin 1(Ang-1) and Ang-2.Vascular endothelial growth factor(VEGF) and monocyte chemoattractant protein-1(MCP-1) were measured in gastric tissue homogenate.To assess whether AKt/phosphatidyl inositol-3-kinase(PI3K) mediated the effect of AGM,an additional group was pretreated with Wortmannin(WM)(inhibitor of Akt/PI3K,15 μg/kg,i.p.),prior to ischemic injury and AGM treatment,and examined histologically and immunostained.Another set of experiments was run to study vascular permeability of the stomach using Evan's blue dye.RESULTS:AGM markedly reduced Evan's blue dye extravasation(3.58 ± 0.975 μg/stomach vs 1.175 ± 0.374 μg/stomach,P < 0.05),VEGF(36.87 ± 2.71 pg/100 mg protein vs 48.4 ± 6.53 pg/100 mg protein,P < 0.05) and MCP-1 tissue level(29.5 ± 7 pg/100 mg protein vs 41.17 ± 10.4 pg/100 mg protein,P < 0.01).It preserved gastric histology and reduced congestion.Ang-1 and Ang-2 immunostaining were reduced in stomach sections of AGM-treated animals.The administration of WM abolished the protective effects of AGM and extensive hemorrhage and ulcerations were seen.CONCLUSION:AGM protects the stomach against I/R injury by reducing vascular permeability and inflammation.This protection is possibly mediated by Akt/PI3K.

Biochemical and radiological predictors of malignant biliary strictures

AIM: Differentiation of benign biliary strictures (BBS) from malignant biliary strictures (MBS) remains difficult despite improvement in imaging and endoscopic techniques. The aim of this study was to identify the clinical, biochemical and or radiological predictors of malignant biliary strictures.METHODS: We retrospectively reviewed all charts of patients who had biliary strictures (BS) on endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous cholangiography (PTC) in case of unsuccessful ERCP from March 1998 to August 2002. Patient characteristics, clinical features, biochemical, radiological and biopsy results were all recorded. Stricture etiology was determined based on cytology,biopsy or clinical follow-up. A receiver operator characteristic (ROC) curve was constructed to determine the optimal laboratory diagnostic criterion threshold in predicting MBS.RESULTS: One hundred twenty six patients with biliary strictures were enrolled, of which 72 were malignant. The mean age for BBS was 53 years compared to 62.4 years for MBS (P=0.0006). Distal bile duct stricture was mainly due to a malignant process 48.6% vs 9% (P=0.001). Alkaline phosphates and AST levels were more significantly elevated in MBS (P=0.0002). ROC curve showed that a bilirubin level of 84 μmol/L or more was the most predictive of MBS with a sensitivity of 98.6%, specificity of 59.3% and a positive likelihood ratio of 2.42 (95% CI=0.649-0.810). Proximal biliary dilatation was more frequently encountered in MBS compared to BBS, 73.8% vs39.5% (P=0.0001). Majority of BBS (87%) and MBS (78%) were managed endoscopically.CONCLUSION: A serum bilirubin level of 84 μmol/L or greater is the best predictor of MBS. Older age, proximal biliary dilatation, higher levels of bilirubin, alkaline phosphatase, ALT and AST are all associated with MBS. ERCP is necessary to diagnose and treat benign and malignant biliary strictures.

Double diabetes in Saudi Arabia: A new entity or an underestimated condition

AIM To determine the clinical and biological characteristics of double diabetes(DD) among young people in Saudi Arabia.METHODS This was a retrospective descriptive chart review study including 312 young newly diagnosed diabetic patients(aged 12-20 years), whom were admitted over a five year period(January 2009 to December 2013). Family history of diabetes mellitus(DM)(first degree), physical body mass index(BMI), acanthosis nigricans, history of auto-immune disease and laboratory information for glycosylated hemoglobin, basal C peptide level and diabetes autoantibody response(anti-GAD, anti-IA2 and anti-ICA) were collected from medical report. A mean follow-up of 3 years for these patients was performed.RESULTS Patients were categorized into 4 groups, based on the autoantibody response(Ab+ or Ab-) and C-peptide secretion(β+ for fasting level 0.4-2.1 ng/mL and β- if < 0.4 ng/mL). Group1(type 1a): Ab+ β-(21%), group 2(type 1b): Ab- β-(9%), group 3(DD): Ab+ β+(31%)and group 4(classic type 2 DM): Ab- β+(39%). The mean age of the DD patients in our study was 15.1 ± 6.4 years. A total of 41% of the study population presented with diabetic ketoacidosis and 61% of the study population presented with positive family history of DM. The mean BMI was 26.8 kg/m2 with 64% of overweight or obese patients. Ninety two percent of the patients were started on insulin at the time of diagnosis. During a mean follow-up of 3 years, only 32% of the patients with DD required insulin and 78% were on metformin alone or with insulin. CONCLUSION Our findings enable us to arrive at the conclusion that almost one-third of the young Saudi diabetic patients reveal atypical forms of DM(double diabetes) expressing features resulting from both T1D and T2D.