Abstracts

. 2017 Jan;23(Suppl 1):S1–S19.

Abstracts

PMCID: PMC5333472

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

01: Does Combining Liraglutide With Intragastric Balloon Insertion Improve Sustained Weight Reduction?

Mahmoud Hisham Mosli, Moaiad Elyas

Department of Medicine, King Abdulaziz University, Jeddah, Department of Gastroenterology and Hepatology, Saad Specialist Hospital, Al-Khobar, Kingdom of Saudi Arabia

E-mail: mahmoud.mosli@robartsinc.com

Objective: Intra-gastric balloon (IGB) is an effective and safe method of weight reduction. However, IGBs have been associated with a high rate of weight regain post removal. Accordingly, ways to improve sustained weight reduction including concomitant treatment with GLP-1 agonists have been proposed. This study aims to evaluate the effect of adding Liraglutide to IGB insertion on sustained weight reduction.

Methods: A retrospective analysis of all cases treated with IGB with or without Liraglutide was performed. Outcomes were statistically compared.

Results: 108 patients were included, 64 were treated with IGB alone and 44 with IGB + Liraglutide. Six months after removing IGB, patients treated with IGB + Liraglutide had higher mean weight loss post treatment completion (10.2 ± 6.7 vs. 18.5 ± 7.6, P ≤ 0.0001) than those treated with IGB alone. After adjusting for covariates, patients treated with IGB alone demonstrated a higher mean body weight loss at the time of IGB removal (coefficient 7.71, 95% CI 4.78-10.63), and higher odds of treatment success 6 months post IGB removal (OR = 5.74, 95% CI: 1.79-188.42). Baseline BMI appeared to be a significant predictor of mean body weight loss at the time of balloon removal.

Conclusions: Adding Liraglutide to IGB doesn't appear to decrease the risk of weight regain 6 months post IGB removal.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

02: Risk Stratification of Patients with Crohn's Disease: A Retrospective Analysis of Clinical Decision Making and Its Impact on Long-term Outcome

Mahmoud H. Mosli, Hanadi A. Sabbahi, Hind A. Alyousef, Mada I. Abdulhaq, Afnan A. Hadadi, Emad S. Aljahdali, Hani A. Jawa, Salim M. Bazarah, Yousif Qari

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

E-mail: mahmoud.mosli@robartsinc.com

Background and Aims: Complications such as need for small bowel resections and hospitalization due to Crohn's disease (CD) occur when disease activity persists due to ineffective therapy. Certain high-risk features require early introduction of anti-TNF therapy to prevent such complications. We aim to evaluate the prevalence of high-risk features among a cohort of patients with CD and examine the association between discordance of early therapy with baseline risk stratification and disease outcome.

Patients and Methods: All adult patients with CD were retrospectively identified and their medical records were reviewed. Clinical, endoscopic, laboratory and radiological data were collected. Patients were divided into “low” and “high” risk groups according to the presence or absence of penetrating disease, perianal involvement, foregut involvement, extensive disease seen on endoscopy or cross sectional imaging, young age at the time of diagnosis (<40), persistent cigarette smoking and frequent early requirements for corticosteroid therapy. Initial treatment selection and treatment approach (”step up” vs. “accelerated step-up” vs. “top-down”) within 6 months of diagnosis was recorded. Rates of CD-related bowel resections and hospitalization within 5 years of diagnosis were calculated. Logistic regression analysis was used to examine the association between “discordance” of early treatment selections and risk stratification categories with outcomes.

Results: Eighty-five CD patients were included. Mean age and duration of disease were 27.1 (± 11.7) and 6.4 (± 4.8) years, respectively. Sixty five percent were females and 66% were native Saudi's. Smoking was reported in 12% of patients and perianal disease in 18%. “High-risk” features were identified in 51% of which only 14% were treated with “top-down” therapy and 16% “accelerated step-up” care. “Discordance” occurred in 34% of cases. Bowel resection was required for 15/85 (18%) patients and 32/85 (38%) required at least one hospitalization within 5 years of diagnosis. Logistic regression analysis identified a statistically significant association between “discordance” and need for bowel resections (Odds ratio (OR) = 6.50, 95% confidence interval (CI) = 1.59 – 26.27, P = 0.009), and hospitalizations (OR = 3.01, 95% CI = 1.08 – 8.39, P = 0.035) within 5 years of diagnosis.

Conclusions: “Discordance” between patient risk-profile and treatment selection early in the course of CD has a significant influence on disease outcome, specifically need for bowel resection and hospitalization. Early identification of “high-risk” features could help prevent long-term complications.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

03: A Cross-sectional Survey of Multi-generation Inflammatory Bowel Disease Consanguinity and Its Relationship with Disease Onset

Mahmoud H. Mosli, Abdulelah Alzahrani, Showlag Showlag, Abdullah Alshehri, Ahmed Hejazi, Majed Alnefaie, Adel Almaymuni, Mubarak Abdullah, Mohammed Albeshir, Eman Alsulais, Hani A. Jawa, Emad S. Aljahdali, Salem M. Bazarah, Yousif Qari

Department of Medicine, King Abdulaziz University Hospital, Jeddah, Department of Medicine, King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia

E-mail: mahmoud.mosli@robartsinc.com

Background and Aims: Genetic mutations have constantly been linked with the development of inflammatory bowel disease (IBD) however; a Mendelian mode of transmission has never been proven. Consanguinity is thought to play an important role in phenotypic variations of some hereditary and immune mediated disorders including IBD. The aim of this study is to estimate the prevalence of consanguinity among the ancestors of patients with inflammatory bowel disease (IBD) and examine the effect of various levels of consanguinity on IBD disease onset.

Patients and Methods: Patients with IBD seen at the gastroenterology outpatient clinic of King Abdulaziz University Hospital, Jeddah and King Fahad Specialist Hospital, Dammam were consecutively recruited and surveyed for demographics, disease onset and presence of ancestral consanguinity within three generations. Prevalence of different levels of consanguinity was calculated. Linear regression analysis was used to examine the association between age of IBD onset and consanguinity.

Results: 217 patients were recruited from both sites. Mean age was 32.9 (± 13.4), average age at the time of diagnosis was 18.6 (± 11.5) and average duration of illness was 8.6 (± 7.7). 53.5% were females and 74.2% were native Saudi's. Cigarette smoking was reported in 17.1% of patients. Of the 217 patients, 51% had CD, while the remaining patients had UC. A family history of IBD was reported in 29.5% of patients and consanguinity within three generation of ancestors was reported in 57.6%. Consanguinity in more than one generation was reported in 38.7%, and 17.5% of patients had consanguinity in three consecutive generations. Linear regression analysis did not demonstrate an association between IBD onset and multi-generation consanguinity but identified an association with disease subtype (coefficient = 7.1 (95% CI = 4.1, 10)).

Conclusions: Consanguinity is extremely common among Saudi IBD patients but does not seem to influence age of disease onset. Genetic studies are needed to further clarify the effect of consanguinity on disease behaviour.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

04: A Cross-sectional Survey of Multi-generation Inflammatory Bowel Disease Consanguinity and Its Relationship with Disease Onset

Mahmoud Mosli, Abdulelah Alzahrani, Showlag Showlag, Abdullah Alshehri, Ahmed Hejazi, Majed Alnefaie, Adel Almaymuni, Mubarak Abdullah, Mohammed Albeshir, Eman Alsulais, Hani Jawa, Emad Aljahdali, Salem Bazarah, Yousif Qari

Department of Medicine, King Abdulaziz University Hospital, Jeddah, Department of Medicine, King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia

E-mail: mahmoud.mosli@robartsinc.com

Background and Aims: Genetic mutations have constantly been linked with the development of inflammatory bowel disease (IBD) however; a Mendelian mode of transmission has never been proven. Consanguinity is thought to play an important role in phenotypic variations of some hereditary and immune mediated disorders including IBD. The aim of this study is to estimate the prevalence of consanguinity among the ancestors of patients with inflammatory bowel disease (IBD) and examine the effect of various levels of consanguinity on IBD disease onset.

Patients and Methods: Patients with IBD seen at the gastroenterology outpatient clinic of King Abdulaziz University Hospital, Jeddah and King Fahad Specialist Hospital, Dammam were consecutively recruited and surveyed for demographics, disease onset and presence of ancestral consanguinity within three generations. Prevalence of different levels of consanguinity was calculated. Linear regression analysis was used to examine the association between age of IBD onset and consanguinity.

Results: 217 patients were recruited from both sites. Mean age was 32.9 (± 13.4), average age at the time of diagnosis was 18.6 (± 11.5) and average duration of illness was 8.6 (± 7.7). 53.5% were females and 74.2% were native Saudi's. Cigarette smoking was reported in 17.1% of patients. Of the 217 patients, 51% had CD, while the remaining patients had UC. A family history of IBD was reported in 29.5% of patients and consanguinity within three generation of ancestors was reported in 57.6%. Consanguinity in more than one generation was reported in 38.7%, and 17.5% of patients had consanguinity in three consecutive generations. Linear regression analysis did not demonstrate an association between IBD onset and multi-generation consanguinity but identified an association with disease subtype (coefficient = 7.1 (95% CI = 4.1, 10)).

Conclusions: Consanguinity is extremely common among Saudi IBD patients but does not seem to influence age of disease onset. Genetic studies are needed to further clarify the effect of consanguinity on disease behaviour.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

05: Screening Irritable Bowel Syndrome Patients for Symptoms Predictive of Inflammatory Bowel Disease Using the Red Flag Score

Mahmoud Mosli, Mutaz Bamarhul, Abdulrahman Alharbi, Sohaib Shafei, Ahmad Alharbi, Khalid Bamahfouth, Hani Jawa, Emad Aljahdali, Salim Bazarah, Yousif Qari

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

E-mail: mahmoud.mosli@robartsinc.com

Background and Aims: The diagnosis of inflammatory bowel disease (IBD) is often delayed due to misdiagnosing patients with irritable bowel syndrome (IBS) and as result may lead to the development of complications or decrease future response to therapy. The Red Flag Score (RFS) has been recently developed to identify patients that are at high risk of having IBD rather than IBS. The aim of this study is to estimate the prevalence of “high-risk” features, according to the RFS, among Saudi patients diagnosed with IBS who would as a result be candidates for ileo-colonoscopic evaluation.

Patients and Methods: Adult patients with IBS seen at the general medicine clinic were recruited and surveyed using the RFS. Clinical and demographic data were collected. The prevalence of “high-risk” features defined as a RFS >6 was calculated. Logistic regression analysis was used to identify predictors of an RFS >6.

Results: 255 IBS patients were recruited. Mean age was 30.6 (± 9.9) and 71.4% was females (182/255) and 90.2% were Saudi's (230/255). More than half of patients we surveyed (51.4%) had not been seen by a gastroenterologist in the past. Mean RFS was 6.6 (± 3.6) and 54.9% of patients (140/255) scored more than 6 and accordingly were candidates for further investigations. Statistical analysis identified not previously being seen by a gastroenterologist as the only significant predictor of a RFS ≥6 (OR = 2.2, 95% CI = 1.3-3.7, P = 0.003).

Conclusions: More than half of patients known to have IBS are candidates for further investigations to rule out IBD according to the validated RFS. Patients who self diagnose IBS or who didn't seek a specialized consultation with a gastroenterologist might be at higher risk of being misdiagnosed.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

06: Prevalence and Clinical Predictors of Laryngo-pharyngeal Reflux among Patients Diagnosed with Gastroesophageal Reflux Disease According to the Reflux Symptom Index Questionnaire

Mahmoud Mosli, Bashaer Alkhathlan, Abdulmalek Abumohsen, Hani Jawa, Talal Alkhateeb, Hani Almarzouki

Departments of Medicine and ¹Ear Nose and Throat, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia

E-mail: mahmoud.mosli@robartsinc.com

Background and Aims: Gastroesophageal reflux disease (GERD) is a common condition that can lead to significant morbidity. Laryngo-pharyngeal reflux (LPR) is distinct clinical entity that can occur simultaneously with GERD necessating additional treatment measures. Degree of overlap and clinical predictors of LPR among patients with GERD remains unknown. We aim to measure the prevalence of LPR in patients with GERD and identify clinical predictors.

Patients and Methods: We performed a cross sectional involving patients with confirmed GERD according to the GERD questionnaire (GerdQ) using the reflux symptom index (RSI). Data on demographics, comorbidities, past and current medications, and GERD-related lifestyle measures were documented. Prevalence of LPR was calculated. Linear and logistic regression analyses were used to correlate GerdQ and RSI, and to identify clinical predictors of LPR, respectively.

Results: A total of 80 patients with confirmed GERD were recruited and surveyed. Mean age was 43 (± 16) and 60% were females. The majority of patients were Saudi's (51%) and only 24% were smokers. Mean duration of GERD was 7 (± 4.4) years and average body mass index (BMI) was 36 ± 22. 66% patients consumed coffee on regular basis. On simple and multiple linear regression analysis a strong positive correlation was observed between GerdQ and RSI scores (Coefficient = 1.13, 95% CI = 0.39 – 1.86) and Ipratropium Bromide inhaler was positively associated with RSI scores (Coefficient = 13.12, 95% CI = 0.16-26.09). LPR was identified in 57 patients (71%). On simple and multiple logistic regression analysis, GerdQ scores (OR = 1.78, 95% CI = 1.13-2.80), BMI (OR = 1.07, 95% CI = 1.01-1.14), duration of GERD in years (OR = 1.42, 95% CI = 1.04-1.93), and type of gender (OR = 49.67, 95% CI = 1.32-1870) appeared to increase the risk of LPR while coffee consumption (OR = 0.0005, 95% CI = 1.82e-06 – 0.13) appeared to be protect against LPR.

Conclusions: Contradictory to what is frequently reported; LPR commonly occurs and positively correlates with GERD. Several modifiable clinical predictors of LPR exist, which highlights the importance of performing a complete clinical assessment.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

07: A Cross-sectional Survey of Saudi Gastroenterologists: Transition Strategies for Adolescents with Inflammatory Bowel Disease

Elaf Al-Jahdali, Mahmoud Mosli, Omar Saadah

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

E-mail: mahmoud.mosli@robartsinc.com

Background and Aims: The transition of adolescent with inflammatory bowel disease (IBD) from pediatric to adult care requires a well-structured standardized protocol to ensure the delivery of optimal health care and decrease the risk of non-adherence, hospitalizations, and complications. The aims of this survey is to evaluate current IBD transition practices adopted by gastroenterology services across the Kingdom of Saudi Arabia (KSA), and identify major challenges standing in the way of implementing effective transition strategies from the perspectives of pediatric and adult gastroenterologists.

Patients and Methods: An online survey was distributed to KSA pediatric and adult gastroenterologists through the Kingdom's national gastroenterology association. The questionnaire included closed-ended questions regarding existing institutional transition strategies and perspectives regarding the impact of different factors on their ability to effectively transition adolescents from pediatric to adult care.

Results: A total of 80 adult and pediatric gastroenterologists responded to the survey invitation. Most of the participating Gastroenterologists worked at a tertiary care center (82.5%). The majority of gastroenterologist (73.75%) reported that they do not follow a defined protocol for transition in their current practices. However, a structured transition program was noted to be “very important” by 78.75% gastroenterologist. The most favoured method of transitioning was “Joint outpatient clinic attended by patient, caregiver, pediatric gastroenterologist, and adult gastroenterologist “35.9” and the most commonly reported barrier to transitioning was “lack of proper preparation” for transition (53.16%).

Conclusions: Although acknowledged by the majority of participants as being “very important”, no standardized IBD transition protocol is followed in the majority of practices across KSA. A well-structured national protocol for transitioning adolescents with IBD is needed.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

08: Bile Duct Stones Formed Around a Migrated Clip after Cholecystectomy

Anas Mohammad Hussameddin, Reema Fahad AlOtaibi, Iba Ibrahim AlFawaz, Abdullah AlOtaibi

Gastroenterology Unit, Department of Medicine, Department of Surgery, King Fahad University Hospital, University of Dammam, Dammam, Kingdom of Saudi Arabia

E-mail: ebaafawaz@gmail.com

Background: Surgical clip migration into the common bile duct with subsequent stone formation is a rare complication following laparoscopic cholecystectomy. Very few cases have been reported in the literature.

Presentation of Case: We report a case of bile duct stones formed around a migrated surgical clip 16 years after laparoscopic cholecystectomy. The patient presented with epigastric pain for one day with fever and chills for one week. Investigation with abdominal ultrasound showed dilatation of the common bile duct and moderate dilatation of the intrahepatic bile duct. Diagnosis was suspected when the abdominal CT showed a dense linear structure within the lumen of the distal common bile duct. The diagnosis was confirmed by endoscopic retrograde cholangiopancreatography and the patient was managed successfully with sphincterotomy and stone extraction.

Discussion: The exact mechanism of clip migration is not fully understood. Presenting symptoms are similar to non-clip induced choledocholithiasis. Time of presentation can vary significantly with an average of 26 months. Most cases reported in the literature required surgical intervention.

Conclusion: Clip migration should be considered in the differential diagnosis of post cholecystectomy biliary colic and cholangitis. Management with endoscopic retrograde cholangiopancreatography is the treatment of choice.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

09: Predictors of Unsuccessful Inpatient Colonoscopy Bowel Preparation

Hani Jawa, Mahmoud Mosli, Wafaa Alsamadani, Sondos Noorsaeed, RA Alodaini, Emad Aljahdali, Salim Bazara, Yousif Qari

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

E-mail: jawa.hani@gmail.com

Background and Aims: Adequate colonic cleansing is essential for achieving effective and safe colonoscopy. Inpatient status is one of several factors that have been associated with poor bowel preparation leading to incomplete colonoscopy procedures which in turn may cause increased patient morbidity, missed pathology, prolonged hospital length of stay and cost. Only few studies have assessed predictors of unsuccessful bowel preparation in hospitalized patients. The aim of this study is to identify predictors of unsuccessful bowel preparation for inpatient colonoscopy.

Patients and Methods: Medical records of patients who underwent inpatient colonoscopy at King Abdul-Aziz University Hospital, Jeddah, Saudi Arabia, between January 2015 and June 2016 were reviewed. Demographic, clinical, and endoscopic data were collected. Logistic regression analysis was used to identify predictors of “unsuccessful” bowel preparation. Procedures aborted or repeated due to inadequate bowel preparation were considered “unsuccessful”. Odds ratios (OR) with 95% confidence intervals (CI) were reported.

Results: 130 patients were included in the analysis. Mean age was 58.2 (± 17.3). 51% were males and 51% were native Saudi's. Mean BMI was 26.2 (± 5.8) and most patients were referred from the surgical ward (51%). 57% of patients underwent the procedure before noon and the remaining between noon and 4 pm. The most common indications for inpatient colonoscopies were gastrointestinal bleeding and screening for colorectal cancer and the majority of patients received Meperidine for sedation (38.5%). 23% of patients were known to have hypertension and 14% had history of prior colonic resection. The cecum was reported as intubated in 52% of procedures. Statistical analysis identified procedure time as a significant predictor of bowel preparation success such that procedures performed in the afternoon have lower chances of success (OR = 0.32, 95% CI = 0.14–0.74, P = 0.007), and Aspirin use as a positive predictor for bowel preparation success (OR = 3.1, 95% CI = 1.03–9.24, P = 0.044).

Conclusions: Incomplete colonoscopies for inpatients due to poor bowel preparation are very common. Procedures performed in the afternoon are less likely to be successful.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

10: A Cross-sectional Survey of Primary Health Care Physicians Knowledge, Attitude and Practices of Screening for Colorectal Cancer

Mahmoud Mosli, Yaser Alnahdi, Afnan Hadadi, Abdulsalam Alghamdi, Mohammad Baabdullah, Khaleel Khateery, Ibrahim Alsulami, Abdulaziz AlHoqail, Hani Jawa, Salim Bazarah, Emad Aljahdali, Yousif Qari

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

E-mail: mahmoud.mosli@robartsinc.com

Background and Aims: Early diagnosis of chronic illnesses and cancers mainly occurs at primary health care centers (PHCs) by primary health care physicians (PHPs). The rising incidence of CRC in KSA has been attributed to many factors including non-adherence to screening recommendations. Therefore evaluating PHPs practices and knowledge of screening methods for colorectal cancer (CRC) is clinically important. The purpose of the survey is to evaluate the knowledge, attitude and practices of PHPs regarding CRC screening in KSA and identify factors associated with non-adherence of PHPs to screening recommendations.

Patients and Methods: PHPs working at major hospitals (King Abdulaziz University Hospital, the National Guard Hospital, King Fahad Military Hospital) and PHCs across the city of Jeddah, KSA, were randomly recruited. Participants were surveyed using a comprehensive questionnaire that recorded data on demographics, qualifications, and knowledge of various modalities and guidelines related to CRC screening. Perspectives about effectiveness of screening for CRC, adherence to screening and factors that might have influenced physicians' perspectives or recommendations for CRC screening were also assessed. Logistic regression analysis was used to identify physician characteristics associated with PHPs perspectives of and lack of adherence to screening for CRC.

Results: A total of 127 PHPs were recruited. Average age of participants was 34 (± 8.4) years, 86.6% were native Saudi's, and 56.7% were females. 66.9% of surveys were completed at 24 PHCs and the remaining at hospital-based family medicine clinics. 55% of PHPs had a MBBS degree, and 31.5% were board-certified or carried a PHD in family medicine. 95% of participants believed that CRC screening was effective but as much as 55% reported that they didn't practice screening. Logistic regression analysis did not identify any PHP characteristics associated with lack of PHP belief in CRC screening effectiveness. On the other hand, male physicians (OR = 0.44, 95% CI = 0.19–0.99, P = 0.048) and PHPs with lower qualifications (OR = 0.72, 95% CI = 0.55–0.93, P = 0.011) were less likely to recommend screening for CRC.

Conclusions: A large proportion of PHPs do not adhere to CRC screening despite wide belief that it is effective. Male PHPs with lower qualifications appear to be less likely to recommend screening.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

11: Patient Awareness of Extraintestinal Manifestations in Inflammatory Bowel Disease in Riyadh, Saudi Arabia

Noha Khalid Khalil, Abdullah Alhezaimy, Nourah Faden, Mosfer Aldosari, Fahad Alotaibi, Mohannad Altaib, Salem Thaniah

College of Medicine, King Saudi University, Riyadh, Kingdom of Saudi Arabia

E-mail: Noha.khalid.khalil@gmail.com

Background: Extraintestinal manifestations (EIM) have been reported in approximately 50% of patients with inflammatory bowel disease (IBD); yet there are few studies that address the awareness of IBD population about EIM. Insight into EIM is important to the patient's quality of life and coping with the disease. In this study, we investigated the awareness and source of information of IBD patients about EIM.

Methods: A cross-sectional study was conducted from July 2016 to October 2016, included adults (>18 years) with IBD patients attending gastroenterology clinics at 3 major tertiary hospitals in Riyadh, Saudi Arabia. Data was collected via self-administered questionnaires.

Results: A total of 116 patients, 59 (50.9%) male and 57 (49.1%) female were included in this study; 64 diagnosed with Crohn's disease, 45 with ulcerative colitis, and 7 with IBD-unclassified. Regarding patient's' knowledge about EIM, patients were given 9 EIMs and were asked whether they are associated with IBD or not. None of the participants answered all 9 correctly, the maximum number of correctly answered questions were 7 out of 9. Most of the patients (60%) had 2 or less correct answers and The EIM least known was venous thromboembolism (3%). Other EIM awareness were as follows; oral ulcers (42%), arthritis (41%), osteoporosis (35%), dermatological manifestations (23%), nephrolithiasis (8%), primary sclerosing cholangitis (10%) and ocular inflammation (21%). The most cited source of information about the disease was the treating physician (92%).

Conclusion: Although the majority of respondents demonstrated some awareness of most EIM, programs to increase awareness is highly needed.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

12: Epidemiology of Nonalcoholic Fatty Liver Disease in Saudi Arabia: A Systematic Review

Hadi Mohammed Kuriry, Khalid Bzeizi, Ali Albenmousa, Abdulrahman AlRobayan

Department of Gastroenterology, Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia

E-mail: h.kuriry@live.com

Background: Non-alcoholic fatty liver disease (NAFLD) is a major health concern worldwide and rapidly becoming the most common liver disease worldwide. The worldwide prevalence is 25.24% with highest prevalence in the Middle East and South America.

Methods: Relevant research articles were identified by searching PubMed, MEDLINE and EMBASE, and commercial web sources such as Google Scholar. We searched by using common key words related to non-alcoholic fatty liver disease and steatohepaitis (NASH). The bibliographies of relevant articles were also reviewed to identify other potentially relevant articles.

Results: According to the best available data in Saudi Arabia, the prevalence of NAFLD and NASH was 15.4% and 3.3, respectively. NAFLD patients tend to be males in their forties with mean BMI >30. One-third of NAFLD had advanced fibrosis based on transient elastography. NASH patients tend to be male, younger in age and non-diabetic. NAFLD prevalence among diabetics has been estimated to be 55.6%. Obesity and female gender are independent factors associated with the development of NAFLD in diabetic patients. Obesity, diabetes, hypertension, and dyslipidemia prevalence among NAFLD were estimated to be 91.3%, 50.7%, 44%, and 54.7% respectively.

Conclusion: This systematic review gives a general understanding of the NAFLD epidemiology and highlighted that prevalence studies were severely lacking in Saudi Arabia. NAFLD is coming as major health problem in Saudi Arabia with increase prevalence of risk factors like obesity and diabetes. It is necessary to raise the awareness among general population as well as health care professionals about fatty liver disease.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

13: Role of Serum Talin 1 in Dignosis of Hepatocellular Carcinoma

El Said Hassan Ibrahim, Marwa Mohamed Reda Tawfik, Eman Tayae El Sayed, Doaa Mokhtar Emara, Hend Naguib Abd El Motelub

College of Medicine, Alexandria University, Alexandria, Egypt

E-mail: drmarwareda@hotmail.com

Background: Hepatocellular carcinoma (HCC) is one of the most prevalent cancers with an alarming high rate of morbidity and mortality. Thus, early detection of HCC is crucial for improving the survival rate for patients. Alpha-fetoprotein (AFP) is a widely used tumor marker, but its performance is unsatisfactory with poor sensitivity and specificity. Talin1, is a cytoskeleton protein that is required for cell adhesion and motility and plays a role in tumor migration and metastasis. In the present study, we aimed to study the possible role of Talin1 compared to the traditional biomarker alpha fetoprotein (AFP) in diagnosis and prognosis of HCC.

Methods: To achieve this goal, serum levels of TALIN 1 were quanti fied using ELISA in 90 patients including 30 patients with HCC with tumor characteristic of stages 0, A, B (very early, early, intermediate) according to BCLC (Barcelona-Clinic Liver Cancer), 30 HCC patients with tumor characteristic of stages C, D (advanced, end stage), 15 with liver cirrhosis and 15 healthy controls.

Results: Serum TLN1 in HCC patients were significantly higher compared to the other groups. Also, we found a significant positive correlation between serum TALIN1 and BCLC, tumor size and vascular invasion. ROC curve analysis was used to create a predictive model for TALIN 1 relative to AFP in HCC diagnosis. TLN1 was superior than AFP regarding positive predictive value and negative predictive value in diagnosis of HCC.

Conclusion: We suggest that TALIN1 is involved in the process of the carcinogenesis, infiltration and metastasis of HCC, and hold a promise as a potential marker for HCC diagnosis and prognosis.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

14: Utility of Diffusion Weighted Imaging in Assessment of Liver Fibrosis

Marwa Mohamed Reda Tawfik, Doaa Mokhtar Emara, Doaa Ahmed Elwazzan

Faculty of Medicine, Alexandria University, Alexandria, Egypt

E-mail: drmarwareda@hotmail.com

Background: Radiologic imaging has been used to Estimate Fibrosis. Both CT and conventional MRI did not show high sensitivity for early stages of fibrosis, However, diffusion-weighted magnetic resonance imaging (DW-MRI) has been shown better results in diagnosing early fibrosis.

Methods: This study was conducted on 75 subjects, divided into two groups, 50 cases with chronic viral hepatitis C and 25 age and sex matched healthy subjects with no evidence of liver disease. These cases were referred from hepatobiliary and tropical medicine units to radiology department for DWI-MRI and post processing ADC map. Percutaneous liver biopsy was done for HCV cases for histopathological examination to assess the stage of fibrosis.

Results: In the current study there was a significant relation between the normalized ADC of the liver and the stage of liver fibrosis with AUC = 0.52 and cut off value for stage 3 was 0.52 with a sensitivity and specificity = 61% & 60% respectively. Also, we found the normalized liver ADC distinguished between individual groups of fibrosis with significant differences between control subjects and intermediate stages of fibrosis (stages 2 and 3).

Conclusion: Although DWI-MRI proved to be useful in differentiating different stages of liver fibrosis, in our study, we found overlap between stages F0, F1 and F2 and so DWI/ADC of the liver can divide the patients into two main groups.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

16: Prevalence of Resolved Hepatitis B in Patient with Hepatitis C

Anfal Alshaya, Abdullah Khathlan, Ahmad Al Eid, Asma Sikander, Adel Alqutub, Ahmad Alomair

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

E-mail: dr.khathlan@gmail.com

Background and Aims: According to the recent FDA warning in regard the risk of hepatitis b reactivation during hepatitis c treatment with the direct acting antiviral medications. We wanted to evaluate the patients at risk of such reactivation by screening for the prevalence of hepatitis b previous exposure in our tertiary care center.

Methods: We conducted a retrospective analysis on patients listed for treatment of hepatitis C. We reviewed the percentage of patient with previous exposure to hepatitis B who are at theoretical risk for reactivation be checking for the presence of hepatitis B core antibody.

Results: 103 patient were reviewed, 85% (88/103) had screening for HBV. The incidence of positive HBc antibodies in the screened and the total patients were 24% (21/88) and 20% (21/103) respectively. Patient aged more than 40 had an incidence of positive HBcAb 34% (21/71) and 30% (21/81) in the screened patients and the total patients respectively. While no patients were positive in those less than 40 years of age.

Conclusion: The incidence of previous exposure to Hepatitis b in patients eligible for hepatitis C treatment is not uncommon. One third of the patients older than 40 had prior exposure while patients younger than forty had very low incidence of such exposure.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

17: Evidence of Objective Endoscopic Gastroesophageal Reflux Post Sleeve Gastrectomy

Adnan Al-Zanbagi, Mohammed Ghazi Alharbi, Abdulaziz Mohammed Alzahrani, Mohammed Khan, Zafar Mahmood, M. K. Shariff

Gastroenterology Unit, Department of Medicine, King Abdullah Medical City, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia

E-mail: mkareemshariff@gmail.com

Background: Sleeve Gastrectomy (SG) is a popular bariatric surgery but its link to gastroesophageal reflux (GERD) is a concern as its associated with Barrett's oesophagus (BE). However, the development of GERD following SG is far from clear. Hence, the aim of this study was to look objectively for endoscopic oesophagitis (EE) post SG.

Methods: Hospital records of all patients who had post SG endoscopy were retrospectively reviewed. Demographics, co morbidities, medications used, endoscopic findings and helicobacter pylori status were recorded.

Results: 155 of the 169 patients who had a gastroscopy post SG were included, 14 were excluded as there were done immediately post SG. Median age of patients was 35 years (range 18-65) with 59% (92) females and 48% (74) had hypertension, diabetes mellitus and/or hyperlipidemia. The median post SG endoscopy interval was 16 months (range 7–33). EE was detected in 23% (36) with 64%, 31% and 5% having grade A, B and C respectively. None had hiatus hernia and one of them had a 5cm Barrett's oesophagus (BE). In addition, 26 patients had endoscopy prior to SG of which 15% (4) had oesophagitis post SG and none had oesophagitis prior to SG. 19% (30) were positive for helicobacter pylori (HP) and 23% of these had oesophagitis. Compared to those without HP, the prevalence of oesophagitis was not significantly different (P = 1.00).

Conclusion: Endoscopic oesophagitis was prevalent in nearly a quarter of our study population. The development of EE maybe denovo with the potential to evolve into BE.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

18: Association of Helicobacter pylori with Obesity in the Western Population of Kingdom of Saudi Arabia

Adnan Al-Zanbagi, Sawsan Adil Khan, Saud Owaidh Algethami, Musab Khalaf Alhumaidi, Wafaa Jameel Alharbi, Mahmoud Hassan, M. K. Shariff

Gastroenterology Unit, Department of Medicine, King Abdullah Medical City, Umm Al-QuraTaif University, Makkah, Kingdom of Saudi Arabia

E-mail: mkareemshariff@gmail.com

Background: Prevalence of Helicobacter pylori (HP) in obese patients is conflicting with studies showing a very wide range from 8.7% to 86%. Hence, the aim of this study was to confirm the prevalence of histologically proven HP in obese patients.

Methods: Obese (body mass index (BMI) ≥30, cases) patients who had endoscopy and biopsy for HP in King Abdullah Medical Center (KAMC), Makkah were identified from the hospital information system and their demographics, comobidities and HP status were recorded retrospective.

Results: 468 obese patients (male:female, 1:1.7) with mean age of 48.3 (SD ± 15) years and mean BMI of 44.43 kg/m² were analyzed. The prevalence of HP was 35% (166/469). There was no significant association of HP infection and gender (P = 0.557). There was no difference between the mean ages of patients infected with HP (40.2 ± 12 years) compared to those who were not (42.46 ± 13.7 years) (P = 0.076). Similarly was the case with glycated haemoglobin (6.79 ± 1.9 in HP positive compared with 6.85 ± 1.7 in HP negative, P = 0.708). However, the mean BMI was significantly higher in HP positive patients (46.75 ± 10.3 kg/m²) compared to HP negative (43.1 ± 8.2 kg/m²) (P = 0.0001). There was a positive linear correlation with BMI and HP prevalence (P = 0.0007) [Table 1].

Table 1.

A comparision of split with whole-dose colonoscopic preparation: A retrospective review of efficacy and tolerability

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Conclusions: The prevalence of HP in our study was positively associated with BMI, rising with increasing BMI. This may have implication for obesity management. Further population based studies are needed to confirm this.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

19: A Comparision of Split with Whole-dose Colonoscopic Preparation: A Retrospective Review of Efficacy and Tolerability

Adnan Al-Zanbagi, Ahmed Mohammed Alzahrani, Abdalrhman Hussain Fatani, Mahmoud Hassan, Adbulaziz Tashkandi, Mohammed Wasim, M. K. Shariff

Gastroenterology Unit, Department of Medicine, King Abdullah Medical City, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia

E-mail: mkareemshariff@gmail.com

Background: Good bowel preparation (BP) is the key to quality colonoscopy. Split-dosing (SD) of BP has been shown to be better than whole-dose (WD). It's not known whether SD will produce similar results in the Kingdom of Saudi Arabia (KSA). The aim of this study was to compare SD with WD of same volume of polyethylene glycol.

Methods: A prospectively maintained BP outcome database was retrospectively reviewed. Endoscopists classification of BP using Boston scale (BS) defined as excellent (score 8-9), adequate (5-7) and poor (<5) along with patients experience was analyzed.

Results: 100 patients (59% males) with mean age of 49.65 (± SD, 14.02) were included, 54% had SD and 46% WD. There was no significant difference in the BP quality between the groups. 50% (27/54) in SD and 46% (21/46) in WD had excellent BP (P = 0.69). Similarly, BP was adequate in 35% (19/54) of SD and 46% (21/46) in WD (P = 0.31) while 15% (8/54) in SD and 8% (4/46) in WD had poor BP (P = 0.54). The mean BS score is shown in the Table 1.

Table 1.

Association of Helicobacter Pylori with obesity in the western Population of kingdom of Suadi Arabia

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Conclusion: Overall the BP was excellent to adequate in 88% of our study population with no significant difference between SD or WD preparation. The results maybe limited due the small number of participants.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

20: Self-Expanding Metallic Stent For Palliation Of Malignant Colorectal Cancer: A Single Tertiary Referral Center Experience

Adnan Al-Zanbagi, Mohammed Hussain Fatani, Hussain Ali Alaidarous, Ishtiaq Ahmed, Laeeque Ahmed, Abdulaziz Tashkandi, Mohammed Khan, Ali Algesry, M. K. Shariff

Gastroenterology Unit, Department of Medicine, King Abdullah Medical City, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia

E-mail: mkareemshariff@gmail.com

Background: 13% of CRC in late stage present with intestinal obstruction and there is no clear consensus on how best to manage this clinical emergency. Purpose of this study was to evaluate the effectiveness of Self-expanding metallic stents (SEMS) placement in CRC stenoses in western region of KSA.

Methods: Retrospective review of SEMS placed in King Abdullah Medical City, Makkah, for histological proven inoperable CRC stenosis was done including, demographics data the success of stent placement, complication, re-intervention and mortality.

Results: 26 SEMS were placed in 25 patients. Median age was 51 years (range 37-84) with 64% (16) males, all CRC had distant metastasis and involved the left side of the colon, except for one located in the hepatic flexure. All SEMS were uncovered with mean length 9 cm. SEMS was placed successfully in all the cases, except one (96%). Two SEMS placements in sigmoid resulted in perforation requiring emergency surgery, both survived till date. One of the SEMS failed to expand despite appropriate placement ending in colostomy. Tumor in-growth in one case resulted in further obstruction 6 months following SEMS placement. This was successfully treated by restenting with SEMS. There was no SEMS migration or bleeding. Mortality was 52% (13). Chemotherapy was given to 56% (14) with one having a perforation. Clinical success of relieving obstruction without complication was achieved in 88%.

Conclusion: Placement of SEMS for palliation of obstruction due to CRC in our center was effective in relieving colonic obstruction with complication rates comparable to other studies.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

22: Epidemiology of Primary Sclerosing Cholangitis in Inflammatory Bowel Disease: A Longitudinal Saudi Cohort Study

Nahla Ali Azzam, Othman Alharbi, Abdulrahman Aljebreen, Mahmoud Mosli¹, Najid Musibeeh, Mashail Alowais, Anfal Alshaya, Majid Almadi

Department of Medicine, Division of Gastroenterology, King Saud University, Riyadh, ¹Department of Medicine, Division of Gastroenterology, King Abdul-Aziz University, Jeddah, Kingdom of Saudi Arabia

E-mail: nahla5_99@yahoo.com

Background and Aim: Although primary sclerosing cholangitis (PSC) is considered the most common hepato-biliary extra-intestinal manifestation of inflammatory bowel disease (IBD), epidemiological data related to PSC in IBD remains sparse. Therefore, we aimed to assess the epidemiology of PSC in patients with IBD using a Saudi cohort of patients with IBD.

Patients and Methods: All patients registered in IBDIS; a national IBD database, diagnosed with PSC based on magnetic resonance cholangiopancreatography (MRCP) criteria, were identified. Data related to demographics, clinical symptoms, laboratory investigations, and endoscopic findings were extracted. Prevalence of PSC in IBD was calculated. Descriptive statistics for the continuous variables were reported as means ± standard deviations (SD) and categorical variables were summarized as frequencies and percentages. Continuous variables were compared using Student's t-test, while categorical variables were compared through Chi-square testing. The level of statistical significance was set at a P-value of <0.05.

Results: A total of 910 patients with IBD were screened. 21 patients were diagnosed with PSC of which 16/284 had ulcerative colitis (UC) and 5 had Crohn's disease (CD). The prevalence of PSC was higher in UC compared with CD (5.33% vs. 1.02%, P < 0.001). A statistically significant association was observed between PSC and UC, low albumin, older age, and elevated total bilirubin, and alkaline phosphatase levels (ALP). No association existed between PSC and gender and or history of cigarette smoking. During a median follow-up time of 42 months, two patients with PSC developed malignancy leading to death. One had cholangiocarcinoma, while the other died of colon cancer.

Conclusion: According to this longitudinal cohort study, PSC among Saudis patients with IBD is similar to that reported in Europe and USA. Patients with PSC are more likely to be old, have UC and present with cholestasis and hypoalbumeninemia.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

24: Clinical Characteristics and Outcomes of Crohns Related Intra-abdominal Collections

Othman Alharbi, Majid Almadi, Nahla Azzam, Abdulrahman Aljebreen, Mahmoud Mosli¹

Department of Medicine, Division of Gastroenterology, King Saud University, Riyadh, ¹Department of Medicine, Division of Gastroenterology, King Abdul-Aziz University, Jeddah, Kingdom of Saudi Arabia

E-mail: nahla5_99@yahoo.com

Background and Aims: Intra-abdominal collections in the form of abscesses or matted bowel loops, called phlegmons, frequently occur in patients with the inflammatory phenotype of Crohn's disease (CD). The clinical characteristics and management of such conditions are not well characterized. We aim to clinically characterize Crohn's related intra-abdominal collections and identify predictors of surgical interventions and time to surgery.

Patients and Methods: We utilized the Saudi Inflammatory Bowel Disease Information System (IBDIS) database to identify all patients treated for either radiologically proven intra-abdominal abscesses or phlegmons since inception. Demographics, clinical data, clinical course and treatment outcomes were recorded. Logistic regression analysis and survival analysis were used to identify predictors of surgical resection and differences in time to surgery between patient subgroups, respectively.

Results: 144 patients were identified. Mean age was 25.6 (± 9.9) and 51% were males. Fifty-nine percent of patients had abscesses larger 3 cm while thirteen percent had smaller abscesses. Twenty-eight percent of patients had a phlegmon. On presentation, the most common reported symptoms were abdominal pain (99%) followed by weight loss (27%). Forty-eight percent of patients were treated with antibiotics during hospitalization for 2.7 weeks on average, the most common antibiotic being metronidazole. Steroids were prescribed for 52% of patients and TNF-alpha antagonists for 18.7%. The most common surgical intervention was ileo-cecal resection in 41% of patients mostly. Surgical intervention mostly occurred within two months of presentation. Although follow up imaging influenced early surgical intervention (P = 0.035), no statistically significant predictor of surgery could be identified from this cohort. Although not statistically significant, time to surgery varied depending on abscess size.

Conclusions: Intra-abdominal collections are operated on in the majority of patients with the decision to perform early surgery being mostly dependent on follow up cross sectional imaging.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

25: Celiac Disease is Common among Patients with Irritable Bowel Syndrome: Local Study from the Western Region of Saudi Arabia

Yasir Mohammed Khayyat

International Medical Centre, Faculty of Medicine, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia

E-mail: yasirkhayyat@hotmail.com

Introduction: Irritable bowel syndrome (IBS) is a common clinical problem in several age groups in Saudi Arabia, reached about 9 % in high school students and up to 40 % in teachers (1, 2). Despite its common occurrence among the population, there is still difficulties to affirm its diagnosis that relates to physician's qualification and practical experience. Effort is needed to correctly manage IBS and identify any coexistent condition that mimic the symptoms especially gluten sensitivity (GS). GS was considered of low prevalence in Asian and Middle Eastern countries compared to high prevalent regions in Europe and North America. Once it is found that IBS like symptoms may herald GS or celiac disease 10 years preceding its diagnosis.

Aim: This local prospective study aims to estimate the prevalence of different subtypes of IBS, celiac disease positive serology and possible association that may exist, in an area of high IBS diagnosis and relatively low prevalence of celiac disease.

Methods: A prospective study at a tertiary care private hospital at the western region of Saudi Arabia over the period of August 2013 to August 2016. Adults above the age of 15 year invited to participate in the study. ROME 3 criteria was used to identify and diagnose different subtypes of IBS as IBS - Pain, IBS - constipation, IBS – Diarrhea and IBS – Mixed. Basic demographic data collected. The patients filled questionnaire that outline questions related to these subtypes. Laboratory work included CBC, Electrolytes, urea, creatinine, TSH, Tissue transglutaminase antibody (TTG) IgA and IgG collected. Patients with positive serology for TTG invited to undergo upper endoscopy and duodenal biopsies to verify features of Gluten sensitivity according to Marsh classification.

Results: 305 patients with IBS of mixed subtypes according to ROME 3 criteria recruited. Predominantly IBS with mixed features 293 patients (96 %), demographic data to be presented in a table. There is 17 (5.6%) positive TTG serology, duodenal biopsies obtained for only 4 patients (2 patients and another 2 patients of Marsh 0 and Marsh 3b classification respectively). There is statistically significant correlation between IBS with diarrhea predominant and positive TTG-IgA as well as IBS-D and age of the patients.

Conclusion: Gluten sensitivity is prevalent in IBS patients especially diarrhea predominant subtype in the area of the study. Performing serological tests and duodenal biopsies for positive cases will improve the overall management of irritable bowel syndrome.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

26: Procedural Competence and Dexterity: A Cross-sectional Study Involving Saudi Surgeons in the Local Context

Mohammed Suliman Alaboud

Department of Surgery, College of Medicine, Sulaiman Al Rajhi Colleges, Al Bukayriyah, Kingdom of Saudi Arabia

E-mail: mohd.alaboud@gmail.com

Background: Left-handed surgeons are procedurally handicapped in some maneuvers during complex surgeries. Despite significant impact of handedness on their surgical performance, diminutive information is available on this topic in general besides the hardships which left-handed surgeons face during their training and professional life. We aimed to study the impact of handedness on surgeons during undergraduate to postgraduate training and surgical practice.

Methods: A cross-sectional study was performed involving surgeons (n = 124) from 13 surgical specialties of six hospitals in Qassim, Saudi Arabia. Eligibility criteria focused on surgeons who trained and later practiced surgery or laparoscopic procedures.

Results: The study included 73.4% (n = 91) male and 26.6% (n = 33) female surgeons (mean age = 37 years). There were 16.1% (n = 20) consultants, 25% (n = 31) residents and 41.9% (n = 51) general surgeons. Out of the 11 left-handed surgeons, 63.6% faced difficulties during training at medical schools. None of them practiced surgical skills under the required guidance and with suitable instruments matching with their dexterity (P = 0.235 and P = 0.015 respectively) despite being knowledgeable about the instruments suited to their dexterity (72.7%; P = 0.105). It is noteworthy that only 18.2% left-handed surgeons faced difficulties while working with instruments unsuited to their left-handedness (P = 0.133) albeit with amended standard techniques (P < 0.001).

Conclusion: Dexterity remains a serious determinant of surgeons performance. It should be considered as an integral part of their undergraduate and post-graduate training with suitable instruments to alleviate intraoperative complications.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

27: Risk Stratification of Patients with Crohn's Disease: A Retrospective Analysis of Clinical Decision-making and Its Impact on Long-term Outcome

Hanadi Abdulrahman Sabbahi, Afnan Ali Hadadi, Hind Abdulaziz AlYousef, Made Ibrahim Abdulhaq

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

E-mail: sabbahi.ha@gmail.com

Background and Aims: Complications such as need for small bowel resections and hospitalization due to Crohn's disease (CD) occur when disease activity persists due to ineffective therapy. Certain high-risk features require early introduction of anti-TNF therapy to prevent such complications. We aim to evaluate the prevalence of high-risk features among a cohort of patients with CD and examine the association between discordance of early therapy with baseline risk stratification and disease complications.

Patients and Methods: All adult patients with CD were retrospectively identified and their medical records were reviewed. Clinical, endoscopic, laboratory and radiological data were collected. Patients were divided into “low” and “high” risk groups according to the presence or absence of penetrating disease, perianal involvement, foregut involvement, extensive disease seen on endoscopy or imaging, young age at the time of diagnosis (<40), persistent cigarette smoking and frequent early requirements for corticosteroid therapy. Initial treatment selection and treatment approach within 6 months of diagnosis was recorded. Rates of bowel resections and hospitalization within 5 years of diagnosis were calculated. Logistic regression analysis was used to examine the association between discordance of early treatment selections and risk stratification categories with outcomes.

Results: Eighty-five CD patients were included. Mean age and duration of illness were 27.1 (± 11.7) and 6.4 (± 4.8) years, respectively. Sixty five percent were females and 66% were native Saudi's. Smoking was reported in 12% of patients and perianal disease in 18%. High-risk features were identified in 51% of which only 14% were treated with top-down therapy and 16% accelerated step-up care. Discordant treatment occurred in 34% of cases. Small bowel resection was needed for 15/85 (18%) patients and 32/85 (38%) required at least one hospitalization. Logistic regression analysis identified a statistically significant association between discordance and need for bowel resections (Odds ratio (OR) = 5.4, 95% confidence interval (CI) = 1.6-17.7, P = 0.006), and hospitalizations (OR) = 3.9, 95% CI = 1.5-10.0, P = 0.005) within 5 years of diagnosis.

Conclusions: Discordance between patient risk-profile and treatment selection early in the course of CD has a significant influence on disease outcomes, specifically need for small bowel resection and hospitalization. Early identification of high-risk features could help prevent long-term complications.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

28: Acute Pancreatitis in Saudi Children: Case-series Over 20 years from a Signal Tertiary Center

Abdulrahman Ibrahim Alabdulkareem, Tameem Mohammad Almahmoud, Husam Abdulrahman Altahan, Sundas Javad, Maher Mohammed AlHatlani

Gastroenterology Unit, Department of Pediatrics, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia

E-mail: 3bdlrahman@gmail.com

Background: We studied etiology, clinical features, investigations and outcome of acute pancreatitis in children.

Methods: Case-series study was conducted at the National Guard Health Affairs, Riyadh. All pediatric patients (n = 52) (up-to 19-year-old) diagnosed with primary AP from 1994-2015 were included. Two excluded due to their missing data. Demographics, clinical features, management and outcome were collected. Descriptive data will be represented as means and stranded deviation for continues data and percentages and frequencies for categorical data.

Results: Fifty encounters (26 males vs. 24 females), in which AP was the primary admitting diagnosis. The mean age at diagnosis was 11 years. Mean length of admission was 10.5 days. Only 9 patients had recurrence of AP. 44% were idiopathic, 22% gallstones, 6% pancreatic divisum, 4% familial hyperlipidemias, 4% Diabetic Ketoacidosis, 4% Post-ERCP, 4% drug-induced. 94% of the patients presented with abdominal pain, 76% vomiting, 20% nausea, 8% fever, 8% jaundice, 2% constipation, 9.26% loss of appetite. KUB was normal in all patients. Ultrasound was normal in 18.42%, while 15.79% didn't have US. 14.47% had enlarged pancreas, 11.84% gallstone, 7.89% peritoneal fluid, 5.26% dilated common bile duct, 3.95% fluid around pancreases, 3.95% dilated intrahepatic duct, 2.63% dilated gallbladder.

Conclusion: Although still relatively uncommon in KSA, on average there are 2-3 cases of childhood AP diagnosed yearly in our institute and the natural history AP is comparable to west.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

29: Direct Acting Antivirals for Hepatitis C Virus in King Saud Medical City, Riyadh, Saudi Arabia: Experiences and Outcome

Thamer A Aldarsouny, Toufiq Semman, Adnan Almostafa, Awadh M Bajubair, Shaker Bakkari, Fahd Al-Harbi, Ibrahim Al-Razuq

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

E-mail: masjubair@yahoo.com

Background: Hepatitis C virus (HCV) is a worldwide infection. The prevalence in Saudi Arabia is between 1-2%. Currently the aim of anti-HCV treatment is the eradication of the virus in the next few years. Newly developed DAAs are potent drugs achieving SVR in above 90% of the patients. This study represents a real-life experience.

Methods: This is a prospective, single centre, cohort study to evaluate the efficacy and side effects of DAAs in the treatment of patients infected with HCV in King Saud Medical City (KSMC) in Riyadh, Saudi Arabia. These patients were regularly followed in specialized hepatology clinic. The primary endpoint was the achievement of SVR12.

Results: A total of 128 HCV-patients were started on DAAs-based therapy at KSMC. Out of them, 87 patients completed treatment course and had HCV RNA result by PCR 12 weeks after end-of-treatment (EOT), 35 patients are currently on treatment, 2 patients lost follow up, 4 patients discontinued treatment due to serious adverse events (2 developed variceal bleeding, 1 died with massive upper GI bleeding at peripheral hospital, and 1 discontinued DAAs after 21 days because of severe fatigability, however she achieved SVR12). Out of the 87 patients, 39 were males (44.8%) and 48 were females (55.2%). The mean age was 54 years (range 20–77 years). 56 patients were naïve (64.4%). 60 patients were genotype 4 (69%). 57 patients were cirrhotic (65.5%). Sofosbuvir-based regimen was the most commonly used DAAs; for 69 patients (79.3%) & especially sofosbuvir/ledipasvir for 44 patients (50.6%). 86 patients (98.9%) achieved undetectable HCV RNA at EOT and 85 patients (97.70%) achieved SVR12. 1 patient did not respond to treatment and 1 patient relapsed.

Conclusion: In our study 97.7% achieved SVR12. Majority (65.5%) of our patients were cirrhotic. The serious adverse events were rare (3%) but they justify regular follow up and monitoring during treatment with DAAs.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

30: Incidence and Predictors of Bleeding Complications in Patients with Liver Cirrhosis

Ameerah Abdullah Alzhrani, Nada Abdulaziz Aldhwaihi, Mohammed Alharbi, Bader Aljarallah

Department of Medicine, Division of Gastroenterology and Hepatology, King Fahad Specialist Hospital, Qassim University, Qassim, Kingdom of Saudi Arabia

E-mail: 321201178@qumed.org

Background: Liver cirrhosis and chronic liver disease constitutes a major health problem in Saudi Arabia. Bleeding complication in cirrhotic is a common and difficult complication. We aims to determine the Incidence of all bleeding complications in patients with liver cirrhosis and the risk factors predict these complications.

Methods: This is a retrospective chart review study from January 1, 2013 up to December 30, 2016. Data is collected from chart and electronic patients records in King Fahad Specialist Hospital and King Saud Hospital in Qassim. Data entry and analysis is carried out using SPSS.

Results: Preliminary results of around 250 cirrhotic with bleeding complications. Bleeding is ranging from minor to major bleeding. Most documented is esophageal bleeding. Minor bleeding is poorly documented.

Conclusion: Cirrhotic patient with bleeding is a major symptoms reported by patient especially vomiting blood.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

31: Management of Hepatitis B Virus in Pregnant Women: Single Center Experience

Arwa Saad Alolyan, Anwar Ali AlSuwailem, Sahar Mohammed Aljumaiah, Badr Aljarallah

Department of Medicine, Division of Gastroenterology and Hepatology, King Fahad Specialist Hospital, Qassim University, Qassim, Kingdom of Saudi Arabia

E-mail: bmj@qumed.edu.sa

Background: Hepatitis B virus disease during the pregnancy is an important health aspect in perinatal care. We, in Saudi Arabia are lackingdata of the quality of medical services and management provided to these patients.

Objective: To evaluate the clinical stage and management options offered for pregnant women with Hepatitis B.

Methods: A retrospective chart review study for all HBV positive pregnant women followed in maternity and children Qassim hospitals from 2000 to 2016using patients electronic and chart health records for data collection.

Results: Our preliminary data showed 50-60 pregnant ladies label with Hepatitis B delivered in the hospital, majority of them in the carrier stage. Not all of them are linked to appropriate management after delivery. Our final results will be available in 6 weeks.

Conclusion: Majority of our pregnant ladies is inactive carrier and not all of them are linked to care afterward.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

32: Safety and Efficacy of Sofosbuvir in Combination with Daclatasvir or Simeprevir with or without Ribavirin in the Treatment of Chronic Hepatitis C Virus Genotype Four-infected Patients: A Real World Experience

Mohamed A. Babatain, Ali H. Albenmousa, Abdullah Alghamdi, Mahdi Aljarodi, Haziz Albiladi, Ashwaq Alshafi, Hammad Alothmani, Faisal Sanai, Khalid Bzeizi

Gastroenterology Unit, Department of Medicine, King Fahad Hospital, Jeddah, Gastroenterology Unit, Department of Medicine, King Abdulaziz Medical City, Jeddah, Department of Gastroenterology, Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia

E-mail: alibenmousa@gmail.com

Background and Aims: Direct acting antiviral regimens containing sofosbuvir (SOF) in combination with either simeprevir (SMV) or daclatasvir (DCV) are very effective in treating hepatitis C virus (HCV) infection particularly genotype (GT)-1 with cure rates exceeding 90%. However, the data on GT4, the most common GT in the Middle East, is very limited, particularly for DCV-based therapies. We aimed to determine the efficacy and safety of SOF in combination with either SMV or DCV in patients with HCV GT4 infection.

Patients and Methods: In this real-life, prospective, observational study, chronic HCV GT4 infected patients (n = 96) were evaluated in two cohorts based on the 12-week treatment regimen they received. Cohort 1 included patients (n = 56) treated with SOF and SMV ± ribavirin (RBV), while Cohort 2 included patients treated with SOF and DCV ± RBV (n = 40). The primary efficacy endpoint was SVR12 while the primary safety endpoint was drug discontinuation and/or occurrence of grade 3/4 adverse events.

Results: The mean age for the whole cohort was 49 ± 14.6 years of whom 59.4% were males. Twenty-seven patients (48.2%) in Cohort 1 (SOF + SMV ± RBV) and 21 patients (52.5%) in Cohort 2 had failed prior interferon (IFN)-based treatment. Cirrhosis was present in 53.6% and 35.0% of Cohort 1 and 2, respectively. The median pretreatment HCV RNA log10 was 6.1 (3.6-7.0) 6.0 (3.6-7.2) IU/mL in cohorts 1 and 2, respectively. RBV was received by 17 patients (30.4%) patients in Cohort 1 and 2 (5%) patients in Cohort 2. SVR12 was achieved in all patients (100%). Adverse events were reported in 32% of patients and all were Grade 1 or 2 with no drug discontinuation due to adverse events and no reported hepatic decompensation during treatment. One death occurred in the SMV group that was considered unrelated to treatment.

Conclusion: The combinations of SOF with SMV or DCV are safe and highly effective in the treatment of chronic HCV GT4 infection. Usual predictors of poor response such as cirrhosis and failure of prior IFN-based treatment did not affect the efficacy of these regimens. Larger real-life studies are needed to confirm these findings.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

33: Does Baseline Alanine Transaminase Level Predict the Necro-inflammatory Score in Autoimmune Hepatitis with Cirrhosis?

Ali Hussain Albenmousa, Abdulrahman Aljumaa, Shefan Hameed, Zahraa Al-Shurafa, Khalid Bzeizi

Department of Gastroenterology, Prince Sultan Military Medical City, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia

E-mail: alibenmousa@gmail.com

Background: The characteristic findings in the liver biopsies constitute an important part of the Auto-immune hepatitis (AIH) diagnostic criteria. Necro-inflammation is usually correlated with serum transaminases in AIH patients. This relationships however is not well defined in patients with cirrhosis, a common finding seen in over 30% of AIH patients.

Aims: To assess the predictability of baseline ALT level for the necro-inflammation score in AIH patients with cirrhosis.

Patients and Methods: A total of 171 consecutive AIH patients presented to two tertiary centers (Prince Sultan Military Medical City and King Abdulaziz Medical City) in Saudi Arabia during the period from January 2005 to December 2014 were included in the analysis. They were divided into three groups. Group 1 patients were biopsy proven AIH cirrhosis and have baseline ALT level less than 1.5X ULN. Group 2 included patients with biopsy proven AIH cirrhosis and a baseline ALT level ≥ than 1.5X ULN. Group 3 included all AIH patients without evidence of cirrhosis and with no condition on their baseline ALT level. The Metavir Score was used to determine the severity of the necro-inflammation. The primary endpoint was the difference in necro-inflammatory score between the groups while secondary endpoints were the progression of disease and prevalence of autoimmune markers.

Results: Twenty-five patients were in group 1, 49 patients in group 2 and 97 patients in group 3. The mean age was significantly higher in Group 1 compared to groups 2 & 3 (49.4 ± 17.3, 35.6 ± 18.2, 33.1 ± 15.4 years respectively, P < 0.001). There was no significant gender distribution difference among the groups (P = 0.537). Severe hepatitis (A3) was the most frequent finding in all the groups. There was no statistically significant difference in all the necro-inflammatory scores among the groups (P = 0.297). There was also no difference in the prevalence of autoantibodies namely ANA (P = 0.882) and ASMA (P = 0.414) and the baseline IgG level (P = 0.151). Progression of disease that required liver transplantation or resulted in death was as expected higher in cirrhotic patients but did not differ between group 1 and 2 (24.0 vs. 20.4%, P = 0.723).

Conclusion: Transaminases level is a poor of necro-inflammtory severity in AIH patients with established cirrhosis. The findings of this study support the important role of liver biopsy in diagnosing AIH regardless of transaminases level.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

34: Efficacy and Safety of Ledipasvir/Sofosbuvir in Treatment of Chronic Hepatitis C Virus Genotype-4 Infection. Real-life Experience

Mohamed Aljawad, Ali Albenmousa, Mahdi Aljarodi, Jawad Bin Ammar, Nasser Hussain Almasri

Gastroenterology Unit, Department of Medicine, Dammam Specialist Hospital, Dammam, Department of Gastroenterology, Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia

E-mail: alibenmousa@gmail.com

Background and Aims: Hepatitis C virus genotype-4 is the commonest genotype in Saudi Arabia. The single tablet combination of ledipasvir/sofosbuvir is widely used for treatment of chronic HCV infection. The data on efficacy of this combination in treatment of HCV genotype-4 from clinical trials is limited however evidence from real-life data is growing. Our aim is to evaluate the efficacy and safety of ledipasvir/sofosbuvir with or without ribavirin in a difficult to treat cohort of HCV genotype-4 infected patients.

Patients and Methods: In this multicenter retrospective cohort study, HCV genotype-4 patients who received the combination of ledipasvir/sofosbuvir were evaluated. All patients who received at least 1 dose of treatment and have (or will be having) SVR 12 HCV-RNA result before poster preparation were enrolled. The cohort included naïve and treatment experienced, cirrhotic and non-cirrhotic patients. The primary efficacy endpoint was SVR12 while the primary safety endpoint was occurrence of grade 3/4 adverse events or discontinuation of treatment due to side effects.

Results: Total of 53 patients were included in the study. The mean age was 51.3 ± 14.8 years and 32.1% were males. Thirty-two patients (60.4%) were non-responder to previous treatment with pegylated interferon and ribavirin while 56.6% were cirrhotic based on fibroscan and three patients had decompensation at the start of treatment. Fifty-one patients received 12 weeks of treatment while one patient had 24 weeks and one patient stopped treatment after 4 weeks because she got pregnant while on treatment. Ribavirin was used in 20 patients (38.7%). All patients (100%) had undetectable HCV-RNA at end of treatment. Post treatment week12 PCR results were available for 36 patients at time of preparing this abstract. SVR was achieved in 33 patients (91.7%). No grade 3/4 adverse events were reported and none of the patients discontinued the medication because of side effects.

Conclusion: The combination of ledipasvir/sofosbuvir with or without ribavirin for 12 weeks is highly effective for treatment of HCV genotype-4 patients. Treatment was well tolerated even in patients with advanced disease.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

35: Health-related Quality of Life among Patients with Liver Cirrhosis

Anas Wael Altwijri, Suhail AlQefari, Badr AlJarallah

Department of Medicine, Division of Gastroenterology and Hepatology, King Fahad Specialist Hospital, Qassim University, Qassim, Kingdom of Saudi Arabia

E-mail: at7117@hotmail.com

Background: Living with liver cirrhosis can have a huge influence on poor Health-Related Quality of Life (HRQOL) on many aspects. Liver cirrhosis is a complication of several chronic liver diseases, like Hepatitis B and C viruses, which are common in Saudi Arabia, and can be a major cause of mortality, morbidity and a notable health burden. We aim to assess health related quality of life in patients with liver cirrhosis and to identify and evaluate the factors associated with poor HRQOL.

Methods: This is a cross-sectional study conducted from 2000 to 2016 using an Arabic-translated version of Liver Disease Symptom Index 2.0 (LDSI 2.0) questionnaire in adult patients diagnosed with liver cirrhosis, of any etiology, who are visiting gastrointestinal outpatient clinics in king Fahad specialist hospital – Qassim. χ² tests will be used for categorical variables and the Mann–Whitney U-test for continuous variables; P < 0.05 will be considered statistically significant.

Results: Liver cirrhosis patients complain of itchiness, joint pain, sleepiness, abdominal pain. Patients usually worry about their disease.

Conclusion: Patient oriented outcomes (PROs) warrant more attention in clinical practice.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

36: Challenges in the Management of Mucocele of the Gallbladder Presenting as Chronic Recurrent Biliary Colic

Bader Hamza Shirah, Hamza Asaad Shirah

King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Department of General Surgery, Al Ansar General Hospital, Medina, Kingdom of Saudi Arabia

E-mail: shirah007@ksau-hs.edu.sa

Background: Mucocele of the gallbladder is an over distended gallbladder filled with mucoid content. It is under-reported, and literature review showed insufficient data about the incidence and demographic features. We aim to evaluate the factors influencing the outcome of the treatment in 57 patients proven to have had mucocele of the gallbladder.

Methods: A prospective cohort database analysis of the results of 974 patients who were diagnosed and treated for gallstone diseases between January 2003 and December 2012 was done. Among them, 57 (5.85%) patients were diagnosed as mucocele of the gallbladder. Diagnostic results, ultrasound findings, operative diagnosis, duration of symptoms, the length of hospitalization, and complications were analyzed.

Results: 57 (5.85%) patients were diagnosed as mucocele of the gallbladder. The incidence rate was 5.85 %. Male to female ratio was 1:1.48, and the mean age of patients was 37.41 ± 7.12 years. Ultrasound suspected mucocele in 24 (42%) patients. Laparoscopic cholecystectomy was performed in all 57 (100%) patients, and aspiration of mucoid fluid was done to all. Collapsing of the gallbladder wall was a keystone in the non-complicated laparoscopic procedure. Morbidity and mortality rates were recorded as zero (0%).

Conclusion: We conclude that laparoscopic cholecystectomy is a safe and easy procedure to manage mucocele of the gallbladder with morbidity and mortality rates as low as 0%. The most important factor influencing the success of the procedure is the intraoperative aspiration of the mucoid contents of the gallbladder.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

37: Mirizzi Syndrome: A Challenge to Overcome the Dilemma

Bader Hamza Shirah, Hamza Asaad Shirah

King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Department of General Surgery, Al Ansar General Hospital, Medina, Kingdom of Saudi Arabia

E-mail: shirah007@ksau-hs.edu.sa

Background: The challenging dilemma of Mirizzi syndrome for the operating surgeons arises from the difficulty to diagnose it preoperatively, and about 50% of the cases are diagnosed intraoperatively. In this paper, we aim to analyze the effectiveness of the diagnostic modalities and treatment options in our series of Mirizzi Syndrome in 64 Saudi Arabian patients.

Methods: Included patients had a preoperative or intraoperative diagnosis of Mirizzi syndrome, and were classified into three groups: Group 1: Incidental finding of Mirizzi syndrome intraoperatively (34 patients). Group 2: Patients presented with jaundice, diagnosed by ERCP (17 patients). Group 3: Patients diagnosed initially by ultrasound (13 patients). Laparoscopic cholecystectomy was performed in all 49 patients with Cendes Type I disease. Partial cholecystectomy, CBD exploration, repair of fistula and t-tube placement was done in 8 patients with Cendes type II and 5 with Cendes type III. Partial cholecystectomy with Roux-en-Y hepaticojejunostomy was done in 2 patients with Cendes type IV disease.

Results: 64 patients were diagnosed with Mirizzi syndrome, 49 (76.6%) females, and 15 (23.4%) males. The mean age was 41 years. The morbidity rate was 3.1%. The mortality rate was 0%.

Conclusion: Suspected cases of Mirizzi syndrome should not be underestimated. Difficulty in establishing the preoperative diagnosis is the major dilemma. As it is mostly encountered intraoperatively, the approach should be careful and logic to identify the correct type of Mirizzi by a thorough diagnostic laparoscopy and thus, provide the optimum treatment for the particular subtype aiming to achieve the best management outcome.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

38: The Clinical Pattern of Postcholecystectomy Syndrome in the Local Saudi Arabian Community

Bader Hamza Shirah, Khalid B. Albeladi, Hamza Asaad Shirah, Syed Husham Zafa

King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Department of General Surgery, Al Ansar General Hospital, Department of Medicine, Al Ansar General Hospital, Medina, Kingdom of Saudi Arabia

E-mail: shirah007@ksau-hs.edu.sa

Background: Postcholecystectomy syndrome represents a heterogeneous group of symptoms and findings in patients who have previously undergone cholecystectomy. In this study, we aim to analyze the causes and evaluate the approach to the postcholecystectomy syndrome in our local Saudi Arabian community because of the vast number of cases encountered in our hospital for gallbladder clinical conditions and its related complications.

Methods: 272 patients who were diagnosed and treated for postcholecystectomy syndrome between January 2000 and December 2013 were reviewed.

Results: The incidence rate of the postcholecystectomy syndrome was 19.8%. The mean age was 37.41 ± 7.12 years. The most common causes were: No obvious cause in 50 (18.4%) patients, Helicobacter pylori infection in 43 (15.8%), pancreatitis in 42 (15.4%), peptic ulcer disease in 41 (15.1%), recurrent CBD stone in 26 (9.6%), retained CBD stone in 22 (8.1%), bile leakage in 19 (7%), stenosis of the sphincter of Oddi in 12 (4.4%), cystic duct stump syndrome in 11 (4%), and CBD Stricture in 5 (1.8%). The mortality rate was 0%.

Conclusion: Any clinical presentation postcholecystectomy should not be underestimated and should be thoroughly investigated. Multidisciplinary collaboration is crucial for the best outcome and the safe approach to all the patients. We recommend conducting scientific, clinical studies to investigate the postcholecystectomy syndrome in Saudi Arabia. We also encourage all medical centers dealing with quite good numbers of patients of gallstones and diseases to report their result for the accumulation of sufficient clinical data and exploring the different management approaches and strategies.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

42: Role of miRNA-126 in Hepatocellular Carcinoma and Cholangiocellular Carcinoma

Samar Abdullah Zailaie, Consolato Maria Sergi

Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada

E-mail: samarzail@hotmail.com

Hepatocellular carcinoma (HCC) and Cholangiocellular Carcinoma (CCA) represent the most common malignant tumor of the liver accounting about 90 % of all liver malignances. The overall prognosis of HCC and CCA is very poor due to the lack of effective treatment. MicroRNAs (miRNAs) represent a small endogenous non-coding RNAs that play a significant role in the regulation of gene expression post-transcriptionally. Altered expression of miRNAs has been observed in many malignances including liver cancer. However, the expression level of miR-126 in HCC and CCA and its role in hepatic-carcinogenesis remains unclear. This thesis aimed to study the expression level, localization and biological significance of miRNA-126 in HCC and CCA. In an effort to distinguish the expression pattern of miR-126 in HCC and CCA tissues and cell lines, two expression analysis has been used: in situ hybridization (ISH) and quantitative real time polymers chain reaction (QRT-PCR). Our ISH analysis has shown a significant reduction in miR-126 level in HCC and CCA tissues relative to their corresponding normal tissues. Moreover, an intensive expression of miR-126 in normal hepatocyte, blood vessels and sinusoid cells has been observed. Our qRT-PCR data demonstrated a lower expression level of miR-126 in HCC and CCA cell lines relative to a normal kidney cell line. By using several gain of functions analysis, this study demonstrated the effect of miR-126 in HCC and CCA cell lines. The over-expression of miR-126 in HepG2 and HuccT1 has significantly inhibited cell proliferation and growth. On the other hand, our data has shown that miR-126 overexpression inhibited cell ability to migrate. Taken together, this study indicted that miR-126 could play a critical role in hepatic carcinogenesis. Indeed, miR-126 may serve as a novel suppressive miRNA in liver cancer. Furthermore, miR-126 may serve as potential therapy, diagnostic and prognostic biomarker.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

44: Loss of sAg in Hepatitis B Virus Inactive Carriers, Incidence and Predictors

Ali Albenmousa, Abdulaziz Hamam, Abdullah Madani, Nasser Almasri

Department of Gastroenterology and Hepatology, Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia

E-mail: alibenmousa@gmail.com

Background: Hepatitis B virus infection is a common health problem all over the world with higher prevalence in certain regions like South West Asia. The prevalence in Saudi Arabia is estimated to be 1%–2% with significant decline since the introduction of mandatory vaccination of newborns. Majority of infected patients are inactive carriers and they don't require treatment however they still have low risk of development of chronic liver disease and/or hepatocellular carcinoma. Loss of sAg is considered a cure of the disease. The rate of sAg loss is reported from international studies to be 1% annually however this rate is not known in Saudi Arabia.

Aims: To estimate the rate of sAg loss in HBV inactive carriers and to investigate the factors that can predict the loss of sAg in these patients.

Patients and Methods: A retrospective chart review was carried out for HBV infected patients who presented to Prince Sultan Military Medical City between Jan 2005 and Dec 2015. Inactive HBV carriers were identified based on the hepatologist diagnosis and we excluded patients who had anti-HBV treatment for any indication (like prophylaxis) and those who had high grade fibrosis (>F1) on fibroscan or liver biopsy. All patients had their demographic, biochemical, radiological, histological and serological data collected and analyzed descriptively and inferentially with SPSS version 17. The sAg loss was defined by a negative qualitative test for HBs Ag that was confirmed twice in the same hospital.

Results: We included 268 patients in the study. The mean age at time of presentation was 44.1Ã,Â ± 11.4 years and 63.1% were males. Liver enzymes were elevated in 85% while 15% had persistently normal ALT. After a median follow up of 28 months, 33 patients (12.3%) lost their sAg and had undetectable HBV DNA. The only predictor for sAg loss in this cohort was the baseline HBV DNA. The median HBV DNA in patients who lost sAg and those who remained positive was 350 and 25 iu/ml respectively (P = 0.001). Age, gender, duration of follow up and co-morbidities were not found to be statistically different between groups.

Conclusion: Loss of sAg is not uncommon in HBV inactive carriers and a lower baseline HBV DNA is the best predictor for this phenomenon. Monitoring of HBs Ag is advised during follow up of HBV inactive carrier to avoid unnecessary more expensive testing in these patients.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

46: The Efficacy of Spatz3 Intragastric Balloon in Treatment of Obesity: An Interim Analysis

Mohammed Khan, Adnan Al-Zanbagi, Laeeque Ahmed, Abdulaziz Tashkandi, Hassan Al-Salami, Yasir Mohey, M. K. Shariff

Gastroenterology Unit, Department of Medicine, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia

E-mail: dr_khan78@hotmail.com

Background: Intragastric balloon have gained popularity as a less invasive method of weight loss. Spatz3, a new generation intragastric balloon with a softer catheter provides a unique adjustable feature making it more tolerable and durable. The outcome in weight reduction of this balloon is not well documented.

Aim: To evaluate the efficacy, tolerability and safety of Spatz3 in treatment of obesity.

Methods: All patients who had a Spatz3 balloon inserted in our center and completed 6 months were analyzed retrospectively for the amount of weight loss and complications related to the balloon.

Result: A total of 48 patients (50% females) with mean age of 38.2 years (SD ± 9.68) and mean initial BMI of 60.95 kg/m² (SD ± 16.38) had the Spatz3 balloon inserted. At the end of 6 months the mean BMI decreased by 6.01 units. The mean total body weight loss, percentage of loss of initial body weight and percentage of excess body weight loss (% EWL) was 15.61 kg, 9.5% and 19.79%, respectively. % EWL was achieved in 25% (12) of patients. 17% (8) developed abdominal pain which was mild to moderate, except in one case which was severe leading to the balloon removal after 13 days of insertion. Vomiting requiring medication was experienced by 6% (3).

Conclusion: Spatz 3 was well tolerated with no major complications and achieved nearly 20% EWL. We continue to monitor these patients to look for long term outcomes.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

47: Treatment of Chronic Hepatitis C Genotype Four-infected Patients with Ombitasvir/Paritaprevir/Ritonavir Plus Ribavirin: Real Life Data From Saudi Arabia

Khalid A. Alswat, Awny A. Abdelrahman, Waleed K. Al-Hamoudi, Ayman Abdo, Mohammed A. Babatin, Abdullah S. Alghamdi, Faisal M. Sanai

Liver Disease Research Center, College of Medicine, King Saud University, Riyadh, Gastroenterology Unit, Department of Medicine, King Fahad Hospital, Department of Medicine, Division of Gastroenterology, King Abdulaziz Medical City, National Guard Health Affairs, Jeddah, Kingdom of Saudi Arabia

E-mail: kalswat@ksu.edu.sa

Introduction: Clinical trials have shown the efficacy of all oral therapy in the treatment of patients infected with hepatitis C virus (HCV). HCV with genotype 4 (GT4) is the predominant genotype in the Middle East, and is under-represented in clinical trials of new direct-acting antiviral therapy. This study assessed a real-world safety and efficacy of ombitasvir/paritaprevir/ritonavir (OBV/PTV/r) plus ribavirin (RBV) in patients with HCV GT4 chronic infection.

Methods: In this prospective observational cohort, we enrolled treatment naïve and- experienced HCV GT4 with or without cirrhosis for a 12 week treatment regimen with OBV/PTV/r + RBV from June 2015 to March 2016. Patients were consented to prospective data collection and assessed for clinical, laboratory parameters and adverse events every 4 weeks, and monitored as well by dedicated liver clinic coordinators during therapy and follow-up periods.

Results: A total of 117 adult patients with a mean age of 52.8 years were enrolled, 47% were male, 64% with F3/F4 fibrosis, and 44% were treatment-experienced to pegylated interferon and RBV. The mean BMI was 29.12 (17-46) kg/m2, ALT 63 (8.5-322) IU/L, AST 48.1 (13-171.3) IU/L, albumin 37.2 (23-49) g/dL, total bilirubin 9.7 (3.4-28) umol/L, platelets 204 (38-471) 109/L, hemoglobin 13.8 (10.3-17.4) g/dL and HCV RNA 2,482,469 (20,991-16,702,222) IU/mL. Virology response parameters for HCV RNA 12 week post treatment (SVR12) were available for 47 patients at the time of this analysis with SVR12 achieved in 45/47 (96%) patients. HCV RNA was undetectable in 44/47 (94%) patients at on-treatment week 4 and in 47/47 (100%) at the end of treatment. The two relapsers (4%) were both cirrhotic, one was treatment naïve the other was treatment experienced. Safety parameters showed that most frequent side effects were fatigue in 23 (19.6%) patients and grade 3 and 4 anemia in 6 (5.1%) and 2 (1.7%) patients, respectively. Liver decompensation occurred in 1 patient with a full recovery after discontinuation of therapy (after 6 weeks) and this patient achieved SVR12. Treatment was discontinued in 1 patient and RBV dose was reduced or temporarily held in 6 (5.1%) patients.

Conclusions: The interim analysis of this cohort shows that a 12-week regimen of OBV/PTV/r + RBV is highly effective with a favorable safety profile among HCV GT4 patients. SVR12 rates were high in all patient categories regardless of the presence of cirrhosis or prior treatment experience. Treatment was generally well-tolerated with few side effects similar to those reported in the clinical trials with few withdrawal rates. Final results and predictors of treatment failure for the whole cohort will be presented.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

48: High Sustained Virologic Response to Ombitasvir/Paritaprevir/Ritonavir with and without Dasabuvir in Hepatitis C Virus Genotypes One and Four-infected Patients with Stage 4-5 Chronic Kidney Disease

Mohammed Babatin, Abdullah S. Alghamdi, Ahmad Afghani, Khalid A. Alswat, Ashwaq Alsahafi, Abdallah Alaseeri, Mohammed Aseeri, Faisal M. Sanai

Gastroenterology Unit, Department of Medicine, King Fahad Hospital, Jeddah, Gastroenterology Unit, Department of Medicine, King Abdulaziz Medical City, Jeddah, Gastroenterology Unit, Department of Medicine, King Fahad Hospital, Madinah, Liver Disease Research Center, King Saud University, Riyadh, King Fahd Medical City, Riyadh, Kingdom of Saudi Arabia

E-mail: sanaifa@ngha.med.sa

Background: Limited clinical trial data has shown high efficacy of direct-acting antiviral agents (DAAs) in treatment of hepatitis C virus (HCV) genotype (GT)-1 infected patients with severe chronic kidney disease (CKD). There is no data on the efficacy of DAAs in HCV GT4 patients with CKD. This study assessed real-world safety and efficacy of co-formulated ombitasvir/paritaprevir/ritonavir (OBV/PTV/r) in GT4 and (in combination with dasabuvir [DSV]) in GT1-infected patients with severe CKD.

Methods: In this ongoing, observational cohort of chronic HCV (HCV RNA >6 months) patients with severe chronic CKD (<30 mL/min/1.73 m2, MDRD method), we enrolled treatment naïve (n = 25) and pegylated interferon (PegIFN)/ribavirin (RBV)-experienced (n = 23) GT4-infected patients (n = 22) for a 12-week treatment regimen with OBV/PTV/r ± RBV, and in combination with DSV in GT1 patients (n = 26, including 3 with GT1/4 co-infection). RBV was dosed on physician discretion between 200 mg three times/week – 200 mg daily). The primary efficacy endpoint was SVR12 calculated on an intention-to-treat (ITT) basis.

Results: A total of 48 adult patients with a mean age of 44.7 ± 13.2 years, and HCV RNA 5.8 ± 1.0 IU/mL were enrolled; 27 (56.3%) were female, 14 (27.1%) with advanced fibrosis/cirrhosis (F3/F4, Metavir), and 23 (47.9%) were treatment-experienced. Overall, 46 patients (95.8%) were on regular hemodialysis. All patients received concomitant RBV except 7 (14.6%), 3 with GT4 and 4 with GT1b. All patients completed at least 4 weeks on therapy, with HCV RNA <15 IU/mL or undetectable in 46 (95.8%) patients. No virologic breakthroughs were observed in the 39 patients who had completed therapy. SVR12 was achieved in 97.2% of the 36 patients (GT1 = 18 and GT4 = 18) who had completed 12 weeks of post treatment follow-up (F3-4 = 11, F0–2 = 25). One patient died from a myocardial infarction after completing therapy (end-of-treatment [ETR] HCV RNA undetectable) and was considered a treatment failure on an ITT analysis. RBV dose modifications or discontinuations were required in 12/41 (29.3%) patients. Adverse events were mostly grade 1 or 2 and one patient discontinued all therapy after 4 weeks (and achieved SVR12). There was no overall difference in the baseline and post treatment hemoglobin levels.

Conclusion: The interim analysis of this cohort shows that a 12-week regimen of OBV/PTV/r ± DSV with or without RBV is highly effective with a favorable safety profile amongst HCV GT1 and GT4 patients with severe CKD. SVR12 rates were high in all patient categories regardless of the presence of cirrhosis or prior treatment experience. Treatment was generally well tolerated with few side effects.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

49: High Efficacy of Ledipasvir/Sofosbuvir Combination with or without Ribavirin in the Treatment of Chronic Hepatitis C Genotype Four Infected Compensated and Decompensated Cirrhosis Patients: Real Life Data from Saudi Arabia

Faisal M. Sanai, Adnan AlZanbagi, Mohammed A. Babatin, Abdullah S. Alghamdi, Hamdan Alghamdi, Khalid A. Alswat, Abdulrahman A. Aljumah, Abduljaleel M. Al Alwan, Ayman Abdo, Waleed K. Al-Hamoudi, Abdullah Alaseeri, Yaser Dahlan, Ashwaq Alsahafi, Hammad S. Alothmani, Haziz Albiladi, Ibrahim H. Altraif

Department of Medicine, Gastroenterology Unit, King Abdulaziz Medical City, Department of Medicine, Gastroenterology Unit, King Fahad Hospital, Jeddah, Department of Medicine, Gastroenterology Unit, King Abdullah Medical City, Makkah, Department of Hepatobiliary Science and Liver Transplantation, King Abdulaziz Medical City, Department of Medicine, Liver Disease Research Center, Gastroenterology Unit, College of Medicine, King Saud University, Department of Infectious Disease, King Fahd Medical City, Riyadh, Kingdom of Saudi Arabia

E-mail: sanaifa@ngha.med.sa

Background: Limited clinical trial data has shown high efficacy of co-formulated ledipasvir/sofosbuvir (LDV/SOF) in the treatment of patients infected with hepatitis C virus (HCV) genotype (GT)-4 infected patients, although the data is limited in cirrhotic patients. This study assessed real-world safety and efficacy of co-formulated ledipasvir/sofosbuvir (LDV/SOF) with or without ribavirin (RBV) in GT4 infected patients with compensated and decompensated cirrhosis.

Methods: In this ongoing, observational cohort, we included HCV GT4 treatment naïve and- experienced patients with (n = 40) and without (n = 118) decompensated cirrhosis for a 12-24 week treatment regimen with LDV/SOF. RBV (55.7% of patients) was dosed by physician discretion between 600–1200 mg daily. Patients with prior DAA failure were excluded from the analysis. Compensated cirrhosis (F4, Metavir) was ascertained by Fibroscan. Decompensated cirrhosis (Child's - Pugh score ≥7) was ascertained by established clinical, biochemical and radiological criteria. The primary efficacy endpoint was SVR12 and drug discontinuation and/or occurrence of grade 3/4 adverse events.

Results: A total of 158 adult patients with a mean age of 59.0 ± 29.7 years, and HCV RNA 5.8 ± 0.8 IU/mL were enrolled, 94 (59.5%) were female, and 73 (46.2%) were treatment-experienced to pegylated interferon ± RBV. All patients have completed ≥4 weeks on therapy, with HCV RNA undetectable (<15 IU/mL) in 84/158 (53.1%) patients, and all 129 had reached end-of-therapy with undetectable/below range HCV RNA. No virologic breakthroughs were observed in any of the patients. Overall 81/87 (93.1%) patients who had completed 12 weeks of post treatment follow up achieved SVR12 (compensated cirrhosis, n = 57 [SVR12 91.9%], decompensated cirrhosis, n = 24 [SVR12 96.0%]). Of the 6 patients who failed therapy (all relapsed), one had decompensated cirrhosis while the other 5 had compensated cirrhosis, including 5 who were treatment naïve and 1 being treatment experienced. Four of the 6 patients who failed therapy received concomitant RBV. Adverse events were grade 1 or 2 and there were no drug discontinuations related to side effects. Two patients with decompensated (1 Child's B and 1 Child's C) cirrhosis died from underlying disease progression while on therapy.

Conclusion: The interim analysis of this cohort shows that LDV/SOF with or without RBV is highly effective with a favorable safety profile in HCV GT4 patients with underlying cirrhosis. SVR12 rates were high in all patient categories regardless of the presence of decompensated cirrhosis or prior treatment experience. Treatment was generally well-tolerated with few side effects.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

50: Effect of Intragastric Balloon on Preoperative Weight Reduction in Super Obese Patients

Mohammed Khan, Adnan Al-Zanbagi, Laeeque Ahmed, Salem Al-Otaibi, Abdalrhman Hussain Fatani, M. K. Shariff

Gastroenterology Unit, Department of Medicine, Abdullah Medical City, Makkah, Kingdom of Saudi Arabia

E-mail: dr_khan78@hotmail.com

Background: Pre-operative weight loss of at least 10% of excess body weight has shown to improve both intra and postoperative outcomes especially in super-obese patients. In addition, it can help to select those patients who are complaint and motivated to weight loss before bariatric surgery. Intragastric balloon (IGB) placement has shown mixed results of weight reduction in this population.

Aim: To evaluate the potential benefit of IGB placement in preoperative weight loss in super obese (BMI ≥60 kg/m²) patients listed for bariatric surgery.

Methods: Super obese patients who had an IGB placed at our center before bariatric surgery were retrospectively analyzed for amount of weight loss and safety outcomes at 6 months following placement.

Results: A total of 30 patients with a mean (± SD) age, initial BMI and weight of 40.3 years (± 9.7), 70.92 kg/m² (± 7.23) and 192.6 kg (± 28.77), respectively had IGB placed preoperatively. At the end of 6 months the mean BMI and weight was 65.37 kg/m² and 175.66 kg, respectively. The average weight loss was 17.23 with percentage of excess body weight loss (% EWL) of 13.6%. 18 (60%) patients achieved ≥10% of EWL. Adverse effects in form of abdominal pain and vomiting occurred in 10% (3). In one the pain was severe leading to early removal of IGB. No major complications (bleeding, perforation, migration or intestinal obstruction) were observed.

Conclusion: IGB placement preoperatively was safe, tolerable and achieved the desired weight loss in majority of the super-obese patients.

Saudi J Gastroenterol. 2017 Jan;23(Suppl 1):S1–S19.

54: Hepatitis B Surface Antigen Clearance in Chronic Hepatitis B Patients with Add-on Pegylated Interferon Alfa-2a to Ongoing Tenofovir Treatment: A Randomized Controlled Study

Hamad Al Ashgar, Musthafa Chalikandy Peedikayil, Mohammed Al Quaiz, Fahad Al Sohaibani, Abdulrahman Al Fadda, Mohammed Q. Khan, Einar Thoralsson, Sahar Al Thawadi, Ahmed Al Jedai, Khalid Al Kahtani

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

E-mail: musthafacpdr@gmail.com

Background: The ideal end point of treatment for chronic hepatitis B virus (HBV) infection is sustained off-therapy hepatitis B surface antigen (HBsAg) loss with or even without seroconversion to anti-HBs. We investigated the role of adding Pegylated interferon to ongoing tenofovir treatment in chronic HBV patients for achieving HBsAg clearance.

Methods: In this randomized controlled trial, Chronic HBV patients who have been receiving tenofovir (TDF) for >6 months with HBV viral load <2000 IU/ml were randomized into two groups. One group (add-on therapy) were given subcutaneous Peg IFN 180 mcg weekly for 12 months in addition to tenofovir. Patients in the other group received only tenofovir 300 mg orally on a daily basis. The patients in both groups were followed up for a total of two years, and the patients in both groups were given tenofovir 300 mg daily indefinitely until they developed HBsAg clearance.

Results: Twenty-three patients were allocated to the Peg IFN and tenofovir (add-on therapy), and another 25 patients were recruited to the tenofovir monotherapy. Before randomization, patients had received tenofovir for 1135 mean days (range 203 to 1542 days). One patient (4.3%) in add-on therapy lost HBsAg and seroconverted. Within two years, mean HBsAg decreased significantly with add-on therapy (from 4753 IU/ml to 2402; p-value 0.03); and it decreased from 5957 IU/ml to 4198; p-value 0.09 in the tenofovir monotherapy. More patients in the add-on group developed serious side effects, with treatment discontinuation, and dose reductions (P = 0.3).

Conclusion: PEG IFN and tenofovir add-on therapy were successful in achieving HBsAg clearance and seroconversion in 4.3 percent of the patients. Add-on therapy patients had a significant decrease in HBsAg levels in two years; and no significant decrease in HBsAg levels with the tenofovir monotherapy. With no significant HBsAg clearance, the utility of this combination regimen is questionable.

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Abstracts

01: Does Combining Liraglutide With Intragastric Balloon Insertion Improve Sustained Weight Reduction?

02: Risk Stratification of Patients with Crohn's Disease: A Retrospective Analysis of Clinical Decision Making and Its Impact on Long-term Outcome

03: A Cross-sectional Survey of Multi-generation Inflammatory Bowel Disease Consanguinity and Its Relationship with Disease Onset

04: A Cross-sectional Survey of Multi-generation Inflammatory Bowel Disease Consanguinity and Its Relationship with Disease Onset

05: Screening Irritable Bowel Syndrome Patients for Symptoms Predictive of Inflammatory Bowel Disease Using the Red Flag Score

06: Prevalence and Clinical Predictors of Laryngo-pharyngeal Reflux among Patients Diagnosed with Gastroesophageal Reflux Disease According to the Reflux Symptom Index Questionnaire

07: A Cross-sectional Survey of Saudi Gastroenterologists: Transition Strategies for Adolescents with Inflammatory Bowel Disease

08: Bile Duct Stones Formed Around a Migrated Clip after Cholecystectomy

09: Predictors of Unsuccessful Inpatient Colonoscopy Bowel Preparation

10: A Cross-sectional Survey of Primary Health Care Physicians Knowledge, Attitude and Practices of Screening for Colorectal Cancer

11: Patient Awareness of Extraintestinal Manifestations in Inflammatory Bowel Disease in Riyadh, Saudi Arabia

12: Epidemiology of Nonalcoholic Fatty Liver Disease in Saudi Arabia: A Systematic Review

13: Role of Serum Talin 1 in Dignosis of Hepatocellular Carcinoma

14: Utility of Diffusion Weighted Imaging in Assessment of Liver Fibrosis

16: Prevalence of Resolved Hepatitis B in Patient with Hepatitis C

17: Evidence of Objective Endoscopic Gastroesophageal Reflux Post Sleeve Gastrectomy

18: Association of Helicobacter pylori with Obesity in the Western Population of Kingdom of Saudi Arabia

Table 1.

19: A Comparision of Split with Whole-dose Colonoscopic Preparation: A Retrospective Review of Efficacy and Tolerability

Table 1.

20: Self-Expanding Metallic Stent For Palliation Of Malignant Colorectal Cancer: A Single Tertiary Referral Center Experience

22: Epidemiology of Primary Sclerosing Cholangitis in Inflammatory Bowel Disease: A Longitudinal Saudi Cohort Study

24: Clinical Characteristics and Outcomes of Crohns Related Intra-abdominal Collections

25: Celiac Disease is Common among Patients with Irritable Bowel Syndrome: Local Study from the Western Region of Saudi Arabia

26: Procedural Competence and Dexterity: A Cross-sectional Study Involving Saudi Surgeons in the Local Context

27: Risk Stratification of Patients with Crohn's Disease: A Retrospective Analysis of Clinical Decision-making and Its Impact on Long-term Outcome

28: Acute Pancreatitis in Saudi Children: Case-series Over 20 years from a Signal Tertiary Center

29: Direct Acting Antivirals for Hepatitis C Virus in King Saud Medical City, Riyadh, Saudi Arabia: Experiences and Outcome

30: Incidence and Predictors of Bleeding Complications in Patients with Liver Cirrhosis

31: Management of Hepatitis B Virus in Pregnant Women: Single Center Experience

32: Safety and Efficacy of Sofosbuvir in Combination with Daclatasvir or Simeprevir with or without Ribavirin in the Treatment of Chronic Hepatitis C Virus Genotype Four-infected Patients: A Real World Experience

33: Does Baseline Alanine Transaminase Level Predict the Necro-inflammatory Score in Autoimmune Hepatitis with Cirrhosis?

34: Efficacy and Safety of Ledipasvir/Sofosbuvir in Treatment of Chronic Hepatitis C Virus Genotype-4 Infection. Real-life Experience

35: Health-related Quality of Life among Patients with Liver Cirrhosis

36: Challenges in the Management of Mucocele of the Gallbladder Presenting as Chronic Recurrent Biliary Colic

37: Mirizzi Syndrome: A Challenge to Overcome the Dilemma

38: The Clinical Pattern of Postcholecystectomy Syndrome in the Local Saudi Arabian Community

42: Role of miRNA-126 in Hepatocellular Carcinoma and Cholangiocellular Carcinoma

44: Loss of sAg in Hepatitis B Virus Inactive Carriers, Incidence and Predictors

46: The Efficacy of Spatz3 Intragastric Balloon in Treatment of Obesity: An Interim Analysis

47: Treatment of Chronic Hepatitis C Genotype Four-infected Patients with Ombitasvir/Paritaprevir/Ritonavir Plus Ribavirin: Real Life Data From Saudi Arabia

48: High Sustained Virologic Response to Ombitasvir/Paritaprevir/Ritonavir with and without Dasabuvir in Hepatitis C Virus Genotypes One and Four-infected Patients with Stage 4-5 Chronic Kidney Disease

49: High Efficacy of Ledipasvir/Sofosbuvir Combination with or without Ribavirin in the Treatment of Chronic Hepatitis C Genotype Four Infected Compensated and Decompensated Cirrhosis Patients: Real Life Data from Saudi Arabia

50: Effect of Intragastric Balloon on Preoperative Weight Reduction in Super Obese Patients

54: Hepatitis B Surface Antigen Clearance in Chronic Hepatitis B Patients with Add-on Pegylated Interferon Alfa-2a to Ongoing Tenofovir Treatment: A Randomized Controlled Study

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