Arab Journal of Gastroenterology

Editorial Board

2010-09-01

A note from the Editor’s desk

Abdel Meguid Kassem — 2010-09-01

Dear Colleagues, It is my pleasure to announce the exponential increase of readership of the Arab Journal of Gastroenterology over the last year. It is interesting to note that the number of downloads of full text articles of our Journal from countries outside the Arab region is at least as high as that from Arab countries. We promise to keep you updated with the exciting developments of the Journal.

Preface

2010-09-01

Can a major change in classification, staging and grading of rectal cancer improve planning for treatment, reporting and outcome of the disease?

Ahmed Farag — 2010-08-09

Classification (TNM) staging and histologic grading of rectal cancer has undergone no or minimal changes during the past 20years despite their major impact on planning, reporting and outcome of the disease. The hypothesis forwarded is to replace the classification of cancer rectum from the arbitrary upper-, middle- and lower-thirds using rigid sigmoidoscopy, irrespective of the patient’s stature and body mass index (BMI), with a new intra-peritoneal, anterior and posterior extraperitoneal rectal cancers using preoperative magnetic resonance imaging (MRI). The addition of a letter ‘R’ (for macroscopic or microscopic risk factors) to the TNM as TNMR, the division of the N into ‘‘Microscopic” and ‘‘Macroscopic” or ‘‘Mixed” and Grading (G) of rectal cancer (as GR +ve or −ve), would theoretically warn the treating doctor of the possibility of the need to give adjuvant treatment in otherwise early stages and in apparently low grades of the disease, obviating the need to squeeze those factors into the traditional TNM, for example, version 6, or, more recently, version 7. These changes would hypothetically improve the overall outcome of the disease.

Portal vein thrombosis and haematemesis in chronic liver disease. Are P-selectin and PSGL-1 clues?

2010-08-09

Abstract: Background and study aims: Bleeding and thrombotic complications are common problems in patients with chronic liver disease (CLD). The aim of the present study was to evaluate the level of soluble P (sP)-selectin and P-selectin glycoprotein ligand-1 (PSGL-1) (CD162) expression on neutrophils among patients with CLD and to clarify the role of their interaction, by measuring the platelet leucocyte aggregates, on the clinical outcome of the haemostatic balance in those patients. We also investigated the hypothesis that the balance between platelet activation and endothelial biological function is impaired.Patients and methods: sP-selectin and thrombomodulin (TM) levels were measured by enzyme-linked immunosorbent assay (ELISA) and flowcytometric detection of CD162 was performed. Platelet–leucocyte aggregation (PLA) in whole blood was measured as positive for CD41a and CD45 in 66 CLD patients divided into the portal vein thrombosis group (PVT) (n=25), the haematemesis group (n=21) and the haemostatically stable group (n=20).Results: sP-selectin was significantly elevated in all patient groups. Decreased surface expression of CD162 on neutrophils was detected in all patients’ groups. PLA was statistically significantly increased in the PVT group. TM was statistically significantly increased in the PVT, haematemesis and haemostatically stable groups.Conclusion: PLA may play a role in the unique PVT outcome of the haemostatic balance in a group of patients whose credentials of hyperdynamic portal circulation predispose them to bleeding rather than thrombosis. Consequently, P-selectin-targeted therapy may be used to prevent this complication.

Leptin, osteocalcin, and bone mineral density in post-hepatitic liver cirrhosis

2010-08-18

Abstract: Background and study aims: The pathophysiology of osteoporosis complicating chronic liver disease is unknown. Some studies have found leptin to be a potent inhibitor of bone formation.The aim of this study is to investigate the relationship between leptin, osteocalcin and bone mineral density (BMD) in liver cirrhosis.Patients and methods: Sixty patients with post-hepatitic liver cirrhosis were classified into three groups: Group I, 20 pre-menopausal females; group II, 20 post-menopausal females; and group III, 20 males. In addition, 21 age- and sex-matched healthy subjects (seven for each group) were included as control subjects. Patients were classified according to Child–Pugh classification into grade A (n=0), grade B (n=38) and grade C (n=22). Serum osteocalcin, leptin and parathyroid hormone (PTH), in addition to liver functions test, hepatitis B surface antigen (HBsAg), anti-hepatitis C virus (HCV), serum phosphorus and calcium were measured. Bone mineral density (BMD) was measured by calcaneal ultrasound.Results: Leptin was elevated in all groups (I, II and III) when compared with their control groups (p<0.01, p<0.001 and p<0.01, respectively). Further, it was high in female groups (I and II) compared to males (group III), (p<0.01 each). BMD and serum osteocalcin decreased in each group compared with the respective control (p<0.001; p<0.01 in group I, p<0.05; p<0.001 in group II and p<0.001; p<0.001 in group III, respectively). In the Child–Pugh grade C group, BMD and osteocalcin were low (p<0.001, p<0.05, respectively), while serum leptin was elevated (p<0.05), when compared with grade B group.Leptin correlated negatively with serum osteocalcin (r=−0.553; p<0.001), BMD (r=−0.229; p<0.05), albumin (r=−0.449; p<0.001) and albumin/globulin (A/G) ratio (r=−0.661; p<0.001), while positively correlated with both aspartate transaminase (AST) (r=0.462; p<0.001), and alanine transaminase (ALT) (r=0.483; p<0.001).Osteocalcin negatively correlated with intact iPTH (r=−0.370, p<0.001), while positively correlated with BMD (r=0.418; p<0.001), albumin (r=0.659; p<0.001) and A/G ratio (r=0.444; p<0.001).Conclusion: Serum leptin was elevated in cirrhotic patients and may have a role in the pathogenesis of osteoporosis in liver cirrhosis.

Interstitial pulmonary changes in patients with hepatitis C-related chronic liver disease

2010-08-09

Abstract: Background and study aims: Several extrahepatic manifestations (EHMs) have been reported in the natural history of hepatitis C virus (HCV) infection. Some studies had demonstrated a higher frequency of HCV in patients with idiopathic interstitial pulmonary fibrosis (IPF). The aim of this study is to investigate interstitial pulmonary changes via high-resolution computed tomography (HRCT) and pulmonary function tests (PFTs) in patients with HCV infection.Patients and methods: Forty patients with HCV infection without diagnosis of any pulmonary diseases (group I) and 10 healthy persons (group II) were enrolled in the study. PFT and HRCT were performed in all cases.Results: Findings of interstitial pulmonary involvement were detected in the HRCT of 19 out of 40 patients (47.5%). A decrease lower than 80% of the predicted value was detected in forced vital capacity (FVC) with restrictive pattern together with post-exercise hypoxia, in 21 (52.5%) patients. There was a significant difference between both groups in the findings of HRCT (x2=7.66, df=1, p=0.004) and PFTs (x2=9.05, df=3, p=0.002).According to the Child–Pugh classification, in group I, 15 patients were of class A, 16 were of class B and nine of class C, with no significant difference between classes as regards HRCT findings and PFT values. Six patients were positive for serum cryoglobulins. In these patients, all the parameters were not related to age.Conclusion: Pulmonary interstitial changes are prevalent in HCV-infected patients, irrespective of the severity of their liver condition. It may also occur without respiratory symptoms.

Survivin immunohistochemical expression in hepatocellular carcinoma: Correlation with tumour differentiation and proliferation

Eiman Adel Hasby, Mohammed Alaa Mokhtar — 2010-08-04

Abstract: Background and study aims: Recently, survivin was shown to inhibit apoptosis and accelerate cancer cell proliferation as well. The expression of survivin may be of prognostic significance and therapeutic relevance in many cancers. This study investigated the expression of survivin in hepatocellular carcinoma (HCC); correlated results with tumour differentiation and proliferation (topoisomerase II α) and compared the expression with the surrounding cirrhotic liver tissue.Patients and methods: The expression of survivin and topoisomerase II α was evaluated by immunohistochemistry in 20 cases of HCC and 20 liver cirrhosis tissues. The relationships between two survivin scoring methods – topoisomerase II α nuclear labelling index (LI) and tumour differentiation – were analysed.Results: Eighteen (90%) HCC cases expressed survivin. Median survivin nuclear LI was 75% and 6.5% in HCC and cirrhotic liver tissue, respectively. Median survivin weighted score was 8 and 0 in HCC and cirrhotic liver tissue, respectively. Survivin expression was significantly higher in HCC than in cirrhotic liver tissue (p<0.001). Median survivin expression L1 was 83% and the weighted score was 12 in moderately differentiated HCC versus 33% and 4, respectively in well-differentiated HCC with statistically significant p<0.001. Median topoisomerase II α LI was 22.5% and 3% in HCC and cirrhotic liver tissue respectively, with a statistically significant difference (p<0.001). Median topoisomerase II α was 27.5, 9% in moderately and well-differentiated HCC respectively, with a statistically significant difference (p<0.001). The increase in survivin nuclear expression in HCC correlates significantly with the increase in topoisomerase II α nuclear expression (p<0.001, r=0.987).Conclusion: Both survivin scoring methods were sensitive in discriminating between studied groups; however, nuclear LI showed more specificity. Both survivin and topoisomerase II α expressions were significantly higher in HCC than in cirrhotic liver tissue and correlated significantly with tumour de-differentiation in HCC cases. Survivin nuclear LI correlated significantly with tumour cell proliferation.

Endosonography as a predictive tool for first oesophagogastric variceal bleeding

2010-08-20

Abstract: Background and study aims: Endosonography (EUS) is a useful tool for evaluating the fine details of the vascular structures at the gastroesophageal junction. The aim of this study is to evaluate the value of extraluminal gastroesophageal vascular collaterals as predictors for first variceal bleeding.Patients and methods: Fifty cirrhotic patients with no history of previous upper gastrointestinal (GI) bleeding were recruited into this prospective cohort study. All patients were subjected to upper endoscopy and EUS for assessing the number and size of extramural vascular collaterals and perforating vessels. All patients were followed up for 24±7.5months for upper gastrointestinal bleeding.Results: Eighteen out of 50 patients (36%) had at least one attack of upper GI bleeding during the follow up period. All patients had one or more types of extraluminal venous collaterals. The presence of gastric varices (p=0.02), perigastric collaterals (p=0.03) and perforators (p=0.02) were independent risk factors for first variceal bleeding. The presence of 3 or more paraoesophageal collaterals and the presence of perforators were significantly higher in bleeders when compared to non-bleeders (p=0.034). Perigastric and paragastric collateral sizes were significantly larger in bleeders than in non-bleeders (p=0.019 and 0.038, respectively). Perigastric and paragastric collaterals of size more than or equal to 2mm and 6.20mm, respectively were associated with significantly increased risk of first variceal bleeding.Conclusion: EUS may be a promising tool for predicting first variceal bleeding in cirrhotic patients.

Pattern of bacteraemia following endoscopic elective oesophageal injection sclerotherapy and band ligation in cirrhotic patients

Magdy El Serafy, Mohamad Mahmoud, Mervat Gaber — 2010-08-11

Abstract: Background and study aims: Gastrointestinal endoscopy is an invasive technique and it may be associated with a risk of bacteraemia, especially if endoscopy is associated with an intervention such as injection sclerotherapy or band ligation. The aim of the work is to investigate the incidence of bacteraemia following elective elastic band ligation and elective injection sclerotherapy in cirrhotic patients.Patients and methods: Our study included 80 cirrhotic patients with grade III–IV oesophageal varices divided into three groups: 30 patients treated with elective injection sclerotherapy, 30 patients treated with elective band ligation and 20 patients underwent diagnostic upper endoscopy and served as control. All patients were subjected to full clinical evaluation, abdominal ultrasonography and lab investigations, including blood culture before and after the endoscopic procedure.Results: No positive blood cultures were detected before the technique. Seven patients (8.75%) had positive blood culture after endoscopy; six of them (20%) were in the injection sclerotherapy group, one patient (3.33%) in the band ligation group and none in the upper endoscopy group. Positive blood culture was more frequent in Child C patients (four patients) compared to Child B (two patients) and Child A patients (one patient) with statistically significant difference. Three types of micro-organisms were isolated: Acinetobacter, alpha haemolytic streptococci and coagulase negative staphylococci.Conclusion: The rate of bacteraemia is higher in the injection sclerotherapy group compared with the band ligation group, especially in Child C patients.

Prophylactic embolisation of the left gastric artery in cases with massive upper gastrointestinal haemorrhage with normal angiographic findings

Hany M.A. Seif, Ehab F. Abdou Moustafa — 2010-08-20

Abstract: Background and study aims: The management of massive upper gastrointestinal haemorrhage (UGIH) is problem ridden, especially if the arteriorgraphy shows no pathological findings. Percutaneous embolotherapy of the apparently normal gastric artery could provide a safe haemostatic effect. Our study is a descriptive one aimed to highlight the efficacy and safety of trans-arterial embolisation of the left gastric artery in six cases with massive UGIH and normal angiographic findings.Patients and methods: From January 2004 to December 2008, we performed 24 embolisation procedures for treatment of patients with massive UGIH. All patients had significant bleeding and were referred for arteriography. The outcomes for nine patients having massive UGIH with normal angiographic findings were studied retrospectively. Six of these patients had undergone embolisation of the left gastric artery, whereas the remaining three exsanguinated before embolisation.Results: Nine patients with massive UGIH, who had normal findings on arteriography, were selected to represent the study group. Three patients who did not undergo embolisation exsanguinated after arteriography and two of them died from massive haematemesis. All the six embolised cases showed cessation or marked decrease of bleeding. No major complications were reported during or after embolisation.Conclusion: Left gastric artery embolisation may be a safe and effective method in controlling UGIH with normal angiographic findings, for which both, a large number of patients and a multi-centre study, are recommended.

High quality colonoscopy in a low volume unit; is it achievable?

Ahmed Gado, Basel Ebeid, Anthony Axon — 2010-08-09

Abstract: Background and study aims: Colonoscopy is a technically demanding procedure with potential for harm if performance is poor. Bolak Eldakror Hospital is a secondary-care governmental hospital in Giza, Egypt with an average colonoscopy volume of 28 procedures per year. Our aim was to determine whether a high standard of practice could be achieved in our unit by instituting a rigorous quality assurance programme in spite of a low colonoscopy volume (<50 colonoscopies per year). We assessed the quality of our colonoscopic service with the goal of improving performance.Patients and methods: The crude completion rate was 50% in 2003. The main reasons for failure of completion were operator inexperience, poor patient tolerance and inadequate bowel preparation. Changes were instituted to improve performance. We assessed the quality of our colonoscopic service prospectively over a period of 6years. Colonoscopy completion rates and patient discomfort were considered to be the key measures for improvement. A total of 168 patients undergoing colonoscopies from the year 2004 to 2009 were evaluated.Results: The colonoscopy completion rates improved consistently. The crude completion rate improved from 52% in 2004 to 94% in 2009. The adjusted completion rate improved from 60% in 2004 to 100% in 2009. There were no procedure-related complications. The percentage of patients who experienced moderate or severe pain during colonoscopy was 50% in 2004, increased to 72% in 2007 and improved to 27% in 2009.Conclusion: A high standard of colonoscopy can be achieved in endoscopy units with a low colonoscopy volume by the rigorous application of quality assurance measures.

Massive intrahepatic subcapsular collection associated with parenchymal dehiscence in the case of amoebic liver abscess

Shilpi Singh Gupta, Onkar Singh, Ankur Hastir, Glossy Sabharwal — 2010-08-09

Abstract: We present a case of an amoebic liver abscess that revealed an unusual finding on abdominal computed tomography (CT) scan, an abscess involving the right lobe of the liver and a massive collection almost all around the liver that caused severe indentation of underlying parenchyma. The large amount of subcapsular collection was found to be communicating with the main abscess cavity through a focal parenchymal dehiscence in the supero-posterior region. Glisson’s capsule was intact. Open surgical drainage was performed after a failed attempt of catheter drainage. Such a massive intrahepatic subcapsular collection (4l) in the case of an infection with Entamoeba histolytica is unusual, which, along with the difficulty experienced in treating this case, led us to report it.

Hepatic amyloidosis presenting as intrahepatic cholestasis and portal hypertension: Case series and review of literature

Radha K. Yellapu, Kiranmayi Yellapu, Choudhuri Gour — 2010-08-19

Abstract: Liver involvement in systemic amyloidosis is not uncommon; however, presentation with jaundice is rare. It is considered a preterminal sign. We present four cases of primary AL amyloidosis with severe intrahepatic cholestasis, two of whom presenting also with features of portal hypertension with oesophageal varices. Histopathology revealed diffuse hepatic amyloid deposits in the lobules, portal tracts and sinusoidal space. Review of literature reveals that hepatic amyloidosis presenting with cholestasis and portal hypertension is unusual and portends a poor prognosis.

Brunner’s gland hyperplasia presenting with melena: A case report

Saâd Rifki Jai, Driss Erguibi, Rachid Boufettal, Driss Khaiz, Farid Chehab — 2010-08-19

Brunner’s gland adenoma is a rare duodenal benign tumour, usually located in the duodenal bulb. It is often non-symptomatizing but can occasionally cause digestive haemorrhage or duodenal obstruction , requiring surgical or endoscopic excision of the lesion .

Hepatocellular carcinoma (HCC): a global perspective

2010-06-21

Review team: