Biliary ascariasis: report of a complicated case and literature review

Invasion of the Ascaris worm into the biliary system leads to a wide variety of clinical syndromes. Most of the descriptions of the disease have originated from the developing world, where due to the environmental factors there is a high level of parasitism. An increased incidence of biliary ascariasis borne out of population migration and increased facilities for diagnosis has led to a renewal of interest in this disease in the developed world. Significant morbidity and mortality is associated with the concomitant complications, and early diagnosis and management is of utmost importance. Common disease presentations include biliary colic, obstructive jaundice, acalculous cholecystitis, choledocholithiasis, pancreatitis, and cholangitis. Although with a potential for serious mortality, pancreatitis, and cholangiocarcinoma constitute relatively less common threats. Recent advances in endoscopy have shifted the attention of this disease from the surgeon to the gastroenterologist and a consensus of opinion is arising for early intervention. We present here a patient with biliary ascariasis managed endoscopically and review the epidemiology, prevalence, clinical presentation, diagnosis, and management of this disease.

Acute pancreatitis in Saudi patients

BACKGROUND

The epidemiology of acute pancreatitis in Saudi Arabia is greatly different from that in Western Countries.

AIM

To evaluate and compare the risk factors and clinical features of acute pancreatitis.

PATIENTS AND METHODS

The course of acute pancreatitis was retrospectively analyzed in 218 patients who had their first attack and were admitted at Riyadh Armed Forces Hospital during the period 1.01.85-31.05.97.

RESULTS

From these 218, 130 patients were in the age group of 20-55 yrs. (74+, 56>), 76 were > 55 yrs. Of age (42 +, 34>) and only 12 were < 20 yrs. (6 Females, 6 Males). The precipitating cause was biliary disease in 147, post-operative in ten, hyperlipidemia in seven, post-ERCP in five, infection in four and alcohol in four. Four had rare causes and 37 no obvious cause. Severe pancreatitis diagnosed in 70 patients, 51 of them were > 55 yrs. of age and 45 were precipitated by biliary disease. Twenty six developed complications (21 were > 55 yrs. old) and four deaths. Twenty two patients of these who had severe form had diabetes mellitus, 37 had fever at presentation and 56 had leukocytosis.

CONCLUSIONS

The commonest etiology of acute pancreatitis was biliary in 147 patients (67.5%) followed by postoperative pancreatitis in 10 patients (4.6%). Alcohol as etiological factor was rare (1.8%). The epidemiology and the risk factors differed markedly in Saudi Arabia, where alcohol is prohibited.

Hemophagocytic syndrome

This case report is about an elderly man who presented with a long-standing history of high-grade fever and weight loss. He initially had only hepatosplenomegaly, but then developed jaundice. He also had pancytopenia and raised liver enzymes. His septic screen was negative, but he had a positive Monospot test and immunoglobulin G for Epstein-Barr virus. The liver biopsy showed sinusoidal phagocytosis and the subsequent bone marrow aspiration and biopsy showed significant hemophagocytosis, hence Hemophagocytic syndrome was diagnosed. The fever was refractory to antibiotic and anti-tuberculosis therapy, but it responded only partially to steroids. Full response was only noticed following anti-viral treatment in the form of intravenous Ganciclovir. The patient's general condition, liver enzymes, bilirubin, hematological parameters and even the weight returned back to their normal range 2 weeks after Ganciclovir therapy. Cessation of this drug resulted in relapse of his symptoms and oral antivirals did not help. Splenectomy, steroid pulse therapy and immunosuppressive treatment were only partially helpful. Reintroduction of Ganciclovir did help for a short period. We conclude that our patient had virus-associated hemophagocytic syndrome most likely related to Epstein-Barr virus infection, which was then confirmed by the splenic biopsy, and that Ganciclovir can be of great help in eradicating the virus and treating the disease, provided that it is given for a long enough period.

Gastrointestinal parasites presentations and histological diagnosis from endoscopic biopsies and surgical specimens

OBJECTIVE

To diagnose parasitic ova or worms during endoscopy, surgery or by histology from endoscopic or surgical specimen in our patients.

METHODS

The diagnosis of parasitic disease in our patients was made by histological examinations from biopsies obtained either during an upper gastrointestinal or lower gastrointestinal endoscopy or from surgical specimens.

RESULTS

Parasites were seen in endoscopic biopsies from upper gastrointestinal tract in 21 patients. Schistosoma ova was seen in biopsies from stomach or duodenum (12 patients). Small intestine biopsies showed Giardiasis (8 patients) and strongyloides (1 patient). Colonic biopsies showed schistosoma ova by paraffin section or by squash technique in 216 patients. Surgical specimens from 12 patients, who presented with acute abdomen and had surgery, due to appendicitis in 8 patients, in whom specimens showed (Schistosoma in 5 patients, amoebiasis in 2 patients and Trichuria in 1 patient). Four other patients presented with acute abdomen, where ischemic bowel necrosis or mesenteric vein thrombosis was found during surgery, specimens showed schistosoma ova.

CONCLUSION

The diagnosis of gastrointestinal parasites is not only made by stool but the diagnosis can be made by histology from endoscopic biopsies or surgical specimens.

Gastro-esophageal reflux disease: a small fire which can turn to a volcano

Full text is available as a scanned copy of the original print version.

Upper gastrointestinal endoscopy findings at Riyadh Armed Forces Hospital

Full text is available as a scanned copy of the original print version.

Gastroesophageal reflux disease

In this review of gastroesophageal reflux disease (GERD), we discuss the different aspects of physiology and pathophysiology and then the approach to diagnosis outlining the advantages and disadvantages of each method. The last part of this review covers the management of GERD and advances in this subject with special concentration on other aspects of management such as lifestyle changes followed by drug management.

Helicobacter pylori: Prevalence in 352 consecutive patients with dyspepsia

At the Riyadh Armed Forces Hospital (RAFH), 352 patients had gastroscopy and from each, antral gastric biopsies were taken for identification of Helicobacter pylori, by urease test and histopathology. In 217 (61.64%) of these 352 patients, the histology specimens showed Helicobacter pylori in 73.68% of patients with duodenal ulcer, 70% of patients with gastric ulcers and gastric erosions, 61% of patients with duodenitis and 52% of patients with gastritis. The urease test was positive at six hours in 164 (49.59%) of these 352 patients. The urease test was positive in 60% of each group of patients with endoscopic findings of gastric erosions, gastric ulcers and duodenal erosions.

Endoscopic choledochoduodenostomy (ECDT): A practical approach to management of impacted papillary gallstones and ampullary tumors

We report five cases of impacted papillary stones and two cases of ampullary carcinoma treated by endoscopic choledochoduodenostomy (ECDT) at Riyadh Armed Forces Hospital (RAFH). The procedure was carried out successfully in all five cases with impacted stones and in one of the two cases of ampullary carcinoma. No complications were noted. In the presence of the necessary endoscopic expertise and in cases of impossible cannulation of the papilla of Vater due to stone impaction or the presence of a papillary tumor, we recommend endoscopic choledochoduodenostomy (ECDT). This approach provides an access to the common bile duct thus following appropriate therapeutic procedurs on the biliary system to be performed.

The association between hepatitis C virus antibody and hepatocellular carcinoma in relation to hepatitis B viral infection (RAFH experinece)

Forty-two patients with hepatocellular carcinoma (HCC) were seen during two years at Riyadh Armed Forces Hospital (RAFH), Saudi Arabia. As viral hepatitis is common in this country, serological markers for hepatitis B virus (HBV) and the newly identified hepatitis C virus (HCV) were also studied in these patients. Fourteen (33.3%) patients were HBsAg positive, 11 (26.2%) were anti-HCV positive, two (4.8%) were positive for both HBsAg and anti-HCV and five (11.9%) were anti-HBc and anti-HBs positive. The remaining ten patients all were negative for markers. Serological markers were also studied in 1472 blood donors (control group) during the same period. Twenty-two (1.5%) were positive for anti-HCV, 59 (4%) for HBsAg and two (0.1%) for both markers. Our results are in accordance with previous studies carried out elsewhere, and it is suggested that hepatitis C virus like hepatitis B, may play an important etiological role in hepatocellular carcinoma in Saudi Arabia.

Endoscopic biliary drainage of postoperative biliary fistulae and leak

Five consecutive patients with postoperative biliary fistulae or leak were diagnosed and treated successfully by endoscopic intervention. The development of the fistulae were related to distal common bile duct obstruction by stones in four patients and in one patient by hydatid daughter cysts. Endoscopic sphincterotomy with stone or cyst extractions achieved decompression of the biliary system and initiated closure of the fistulae. In two patients, nasobiliary tube was used and endoscopic endoprosthesis was needed to close the fistula in another patient. In such cases, endoscopic management seems to be superior to surgical re-intervention for repair of fistulae or leak.

Albendazole in hydatid disease: Results in 22 patients

A prospective study to evaluate the effect of albendazole in the treatment of echinococcus granulosus was conducted at the Gastroenterology Unit, Armed Forces Hospital, Riyadh since April 1985 to present involving 22 patients mainly with liver hydatid disease. Of these patients, 30% had a previous history of surgery for recurrence of previously operated hydatid cysts. The duration treatment and follow up period ranged from two months to three years. The only side effect was hair loss in two patients which was fully reversible on the termination of treatment. The following results were achieved: Radiological disappearance of the liver cysts were achieved in eight patients. Four of eight patients were treated only with albendazole and the other four patients with rupture liver cysts to the biliary tree were treated with a combination of non-surgical endoscopic method, hypertonic saline irrigation and albendazole. In the remaining 14 patients, 5 (22.72%) had a 30% to 60% reduction in cyst size. Intracystic change was noted in five patients (22.72%), in two patients the cyst ruptured and there was no change in the cyst size in two patients (9.9%). This study demonstrate that albendazole is a promising drug for the treatment of hydatid disease.

Endoscopic management of bile duct stones at Riyadh Military Hospital: An eight-year experience

Over a period of eight years, 161 Saudi patients with biliary stones underwent 200 endoscopic retrograde cholangiopancreatographic studies at the Armed Forces Hospital, Riyadh, Saudi Arabia. Endoscopic sphincterotomy was performed in 93.2% of these patients and not attempted in the remainder who were referred for surgery because of biliary stones in both the common bile duct and gallbladder. All patients were symptomatic and the most common presenting symptom was biliary colic, seen in 42.2% of these patients. Either acute gallstone pancreatitis or cholangitis was seen in 14.2%, and this resolved completely following gallstone extraction. Endoscopic extraction of common bile duct stones was successful in 138 (85.7%) patients. Failure of stone extraction occurred in nine patients, three of whom received extracorporeal shockwave lithotripsy, which was successful in only one. Complications from endoscopic sphicterotomy and stone extractions occurred in 12 patients, of which bleeding was the most common.