Ibrahim A Al Mofleh

Gastroprotective Effect of an Aqueous Suspension of Black Cumin Nigella sativa on Necrotizing Agents-Induced Gastric Injury in Experimental Animals

Background/Aim Previous studies on “Black seed” or “Black Cumin” Nigella sativa (NS) have reported a large number of pharmacological activities including its anti-ulcer potential. These studies employed either fixed oil, volatile oil components or different solvent extracts. In folkloric practices, NS seeds are taken as such, in the form of coarse dry powder or the powdered seeds are mixed with water. This study examines the effect of NS aqueous suspension on experimentally induced gastric ulcers and basal gastric secretion in rats to rationalize its use by herbal and Unani medicine practitioners. Materials and Methods The study was conducted at the Medicinal, Aromatic and Poisonous Plants Research Center, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia. Acute gastric ulceration was produced by various noxious chemicals (80% ethanol, 0.2 M NaOH, 25% NaCl and indomethacin) in Wistar albino rats. Anti-secretory studies were undertaken in a separate group of rats. Gastric wall mucus contents and non-protein sulfhydryl concentration were estimated, and gastric tissue was examined histopathologically. Results An aqueous suspension of Black seed significantly prevented gastric ulcer formation induced by necrotizing agents. It also significantly ameliorated the ulcer severity and basal gastric acid secretion in pylorus-ligated Shay rats. Moreover, the suspension significantly replenished the ethanol-induced depleted gastric wall mucus content levels and gastric mucosal non-protein sulfhydryl concentration. The anti-ulcer effect was further confirmed histopathologically. Conclusion These findings validate the use of Black seed in gastropathies induced by necrotizing agents. The anti-ulcer effect of NS is possibly prostaglandin-mediated and/or through its antioxidant and anti-secretory activities.

Spontaneous bacterial peritonitis and culture negative neutrocytic ascites in patients with non-alcoholic liver cirrhosis

Abstract Medical records of 18 patients with spontaneous bacterial peritonitis (SBP) and 19 patients with culture negative neutrocytic ascites (CNNA) were reviewed. The diagnosis of SBP was based on a positive ascitic fluid culture, a polymorphonuclear cell count (PMN) greater than 250 cells/mm3 and the absence of an intra‐abdominal source of infection. The diagnosis of CNNA was based on a PMN count greater than 250 cells/mm3, a negative ascitic fluid culture, the absence of an intra‐abdominal source of infection and no antibiotic treatment in the preceding 30 days. All patients in both groups had liver cirrhosis, which was mainly (62.2%) due to HBV infection. A single strain, mostly ‘a Gram‐negative’ bacillus, was recovered from the ascitic fluid culture in the vast majority of patients (83%) with SBP. There were no significant differences between the clinical data of both groups. However, the CNNA group had a significantly better Pugh score (P value = 0.01) with a mean score of 9.42 ±2.24, compared to the SBP group (10.94 ±2.88). The only significant difference in the laboratory data was that the total bilirubin was higher in the SBP group (P 0.01). Hospital mortality was significantly higher in the SBP patients compared to those with CNNA, 50 and 16%, respectively (P 0.03). Recurrent ascitic fluid infection occurred in one of five patients who initially presented. In contrast no recurrence was documented in 12 patients with CNNA.

Nonsteroidal, antiinflammatory drug-induced gastrointestinal injuries and related adverse reactions: Epidemiology, pathogenesis and management

A large proportion of the population all over the world consumes acetylsalicylic acid (ASA: aspirin) or other nonsteroidal, antiinflammatory drugs (NSAIDs). This is associated with a considerable morbidity and mortality. Elderly patients, patients with prior history of peptic ulcer disease (PUD) or its complications, those who require high doses of NSAIDs and those undergoing concomitant therapy with corticosteroids or anticoagulants, are at particularly high risk of developing gastroduodenal injuries and related adverse reactions. Gastroduodenal mucosal injuries induced by NSAIDs vary from subtle microscopic to gross macroscopic changes including ulcers. These injuries are induced by both topical and systemic actions of NSAIDs. Inhibition of gastroduodenal cyclooxygenase (COX) enzyme by NSAIDs is considered to be a major pathogenetic factor. Reactive oxygen species (ROS) appear also to play a significant role in the pathogenesis of mucosal injury. Withdrawal of NSAIDs is preferably the first therapeutic option; however, it is not feasible in the majority of patients. Therefore, several drugs including antisecretory drugs (ASDs-proton pump inhibitors and Histamine-2 receptor antagonists) and misoprostol, a prostaglandin analog are used for the prevention and treatment of NSAID-induced gastroduodenal injuries. Among ASDs, proton pump inhibitors (PPIs) are the most commonly used drugs. The antiulcerogenic effect of PPIs is similar to that of misoprostol and superior to standard doses of histamine-2 receptor antagonists (H2-RAs). The adverse effects of m,isoprostol such as diarrhea, abdominal pain, nausea, flatulence, headache, dyspepsia, vomiting, constipation, abortifacient and teratogenicity limit its general use. Aside from their antisecretory action, PPIs also possess an antioxidative effect. PPI maintenance is recommended in chronic NSAID treatment in those with an increased risk of complications and is more effective than Helicobacter pylori eradication. Low PPI dosage maintenance is as effective as a standard dosage regimen. The effect of H. pylori eradication remains controversial. It is advocated in naοve NSAID users, in chronic users with recent ulcer or ulcer complications and in those with an increased risk of ulcer and ulcer complications. In addition, some herbs have shown inhibition of gastric mucosal damage experimentally induced by necrotizing agents through their antisecretory and antioxidant properties.

Crohn's Disease in a Saudi Outpatient Population: Is it Still Rare?

Background/Aim: To determine the epidemiology of Crohns disease (CD) in an outpatient clinic and compare it with data previously reported from different centers in the Kingdom of Saudi Arabia and outside. Materials and Methods: The medical records of all patients with CD seen in the clinic in the period from January 1993 through December 2007 were reviewed. The demographic, clinical data and methods of diagnosis were retrieved. Results: Over a period of 15 years, we saw 133 Saudi patients with CD. They were predominantly young, with a median age of 26.2 years and male preponderance (2.3:1). The final diagnosis was established within 1 week of presentation in 47% of the patients. The leading symptoms were abdominal pain (88%), diarrhea (70%), bloating (61%), rectal bleeding (50%), weight loss (33%), constipation (24%) and perianal disease (23%). The diagnosis was established by endoscopy and histopathology. Ileocecal involvement was encountered in 40% of the patients. Conclusion: From the current study, it is obviously possible to diagnose a large proportion of patients with CD in a gastroenterology outpatient clinic. The data revealed a strikingly increased incidence of CD in a mainly young Saudi population in the past few years.

Lipid peroxides in patients with inflammatory bowel disease

BACKGROUND/AIMS In this study, we aimed to determine the levels of malondialdehyde (MDA) in patients with inflammatory bowel disease (IBD) to investigate its contribution to tissue injury in IBD. MATERIALS AND METHODS Forty-two patients with IBD (24 cases of Crohns disease and 18 cases of ulcerative colitis) and 38 matched healthy subjects (control group) were considered for study. MDA levels were quantified by the measurement of thiobarbituric acid reactive substances. RESULTS Plasma MDA levels of Crohns disease patients were significantly higher than the control group, but not higher than the ulcerative colitis patients. Plasma MDA levels of patients with ulcerative colitis were higher than the control group but not significant. CONCLUSION Increased levels of plasma MDA in IBD is an important indication of oxidative stress. Patients with Crohns disease are more susceptible to oxidative stress than patients with ulcerative colitis.

Does Helicobacter pylori affect portal hypertensive gastropathy

Helicobacter pylori (H. pylori) is a major etiological factor of peptic ulcer disease (PUD). It is supposed to be a risk factor for the more frequently encountered PUD in patients with liver cirrhosis. Several investigators have evaluated the effect of H. pylori on liver cirrhosis, portal hypertensive gastropathy (PHG) and encephalopathy with controversial results. Some reports have shown a higher seroprevalence and suggested a synergistic effect of H. pylori on liver cirrhosis and PHG. However, this increased prevalence is associated with a negative histology and is not influenced by the cause of cirrhosis, PHG, Child class or gender. Most studies have not found any correlation between H. pylori and PHG. In contrast, other studies have reported a markedly lower prevalence of H. pylori in cirrhotics with duodenal ulcer compared to controls. The aim of this article is to review the relationship between H. pylori infection and portal hypertensive gastropathy and the role of H. pylori eradication in cirrhotic patients.Helicobacter pylori (H. pylori) is a major etiological factor of peptic ulcer disease (PUD). It is supposed to be a risk factor for the more frequently encountered PUD in patients with liver cirrhosis. Several investigators have evaluated the effect of H. pylori on liver cirrhosis, portal hypertensive gastropathy (PHG) and encephalopathy with controversial results. Some reports have shown a higher seroprevalence and suggested a synergistic effect of H. pylori on liver cirrhosis and PHG. However, this increased prevalence is associated with a negative histology and is not influenced by the cause of cirrhosis, PHG, Child class or gender. Most studies have not found any correlation between H. pylori and PHG. In contrast, other studies have reported a markedly lower prevalence of H. pylori in cirrhotics with duodenal ulcer compared to controls. The aim of this article is to review the relationship between H. pylori infection and portal hypertensive gastropathy and the role of H. pylori eradication in cirrhotic patients.

Variceal bleeding: Current issues

Portal hypertension (PHT) is a serious sequel of liver cirrhosis. Eventually, varices develop, grow in size, and bleed. Several diagnostic modalities including transient elastography (TE), capsule endoscopy, CT scanning, and platelets count/spleen diameter ratio (PSR) have recently been introduced. Predictors of bleeding include large varices, red signs, severe liver disease, and hepatic venous pressure gradient (HVPG)12 mmHg. Oral nonselective (NSBB) are recommended for primary prophylaxis in patients with medium-to-large size esophageal varices (EV) that have not bled. Patients with acute variceal bleeding (AVB) should be resuscitated and managed in an intensive care unit. Vasoactive drugs should be started immediately aimed at a better control of bleeding and facilitation of a subsequent endoscopy. Terlipressin controls bleeding and mortality and is considered as the drug of choice. Antibiotic prophylaxis significantly improves survival compared with placebo. Early diagnostic and therapeutic endoscopy in patients with major bleeding enhances control of bleeding, reduces risks of rebleeding and mortality. The use of erythromycin prior to endoscopy clears the stomach, reduces the need for second endoscopy and blood transfusion, and shortens the length of hospital stay. Restricted transfusion strategy prevents portal pressure rise and improves the survival rate. The current recommendation is to treat AVB with a combination of vasoactive agent, EVL, and antibiotics. All patients who survive an episode of AVB should undergo secondary prophylaxis. Transjugular intrahepatic portosystemic shunt (TIPS) using covered stent represents the first-choice rescue treatment. Early TIPS insertion significantly reduces treatment failure, rebleeding, and mortality. Also, insertion of esophageal SX-Ella Danis stent in patients with refractory VB effectively controls bleeding. The data required for this review were obtained mainly through PubMed and Google search.

Saudi journal of gastroenterology: a tale of passion and perseverance.

Someone once said that success is failure turned inside-out. The relevance of those words resonated not too far from our subconscious when, three years ago, the editorial team of the Saudi Journal of Gastroenterology (SJG) sat down to discuss the future of the journal. After 12 years of publishing, SJG was not indexed in any of the major scientific databases and was in a truly dire state of affairs: article submissions were at an all-time low, interest and readership of the journal was flagging and, reflecting a stagnation of purpose, the journal had no electronic version, or an online peer-review system, or a proper scientific publisher. Contrast this with the present situation. Today we stand at the threshold of success. In July 2009, SJG became indexed in PubMed and also became included in Index Medicus/MEDLINE. In their review of the journal, SJG was considered ‘essential’ reading for clinicians in the field and in the region. This is a very prestigious achievement as only six biomedical journals from Saudi Arabia are listed in this index. This also makes SJG the only indexed gastroenterology/hepatology journal from the Middle-Eastern region. The journal is also archived with PubMed Central, making it compliant with the open access policy of the National Institute of Health, USA. In 1994, the Board of Directors of the Saudi Gastroenterology Association (SGA), under the pioneering leadership of its first president, Prof. Faleh Al Faleh,[1,2] appointed Professors Mohammed El Mouzan and Ibrahim Al Mofleh as the founding editors of SJG. The task of laying the foundation for a new scientific medical journal was not easy. The challenge was in the struggle, marked by poor resources of a fledgling association and paucity of scientific data from the region. Into this stepped the grit and determination of the editorial team who poured their personal time, effort and resources into the Journal, soliciting articles from leading authors across the world and plying a system unabashedly tilted towards established international journals. There was no technical help for the journal, no English language editor available, and certainly no wealth of prior experience in journal management. Galley proofs required manual corrections by the editorial team, corrected word-by-word and page-by-page in the most tedious manner imaginable. Grammar, syntax, language, style and even content were all corrected and managed by the editorial team. A determination to succeed was thus the only factor that made the team persevere. Such were the challenges confronted by the editors, from which we can but only take pride in the results they have borne today. There were some bright sparks, though. First there was the enthusiasm of the Saudi gastroenterology community which included amongst them the philanthropy of Dr. Mohammed Al-Mofarreh who contributed financially and scientifically to the journal, and the benevolence of the Dallah Hospital in Riyadh that provided financial and administrative support during the early years of the journal. But the success of a journal cannot be brought about by individual philanthropy and the interest of a few scientific contributors; a scientific journal must harness the potential to reach out to the greater scientific community at large. And then, only then, can it muster the staying power essential within the community of ever-expanding lists of medical journals. It was in this scenario that SJG reached out to Medknow Publications, a scientific publishing house which was both, affordable and efficient, and ideally placed to suit the needs of evolving biomedical journals from the developing world. Medknow Publications did not merely serve as publishers for SJG; they fulfilled a parallel role of an advisory body. By joining hands with Medknow, the journal was immediately launched online thereby improving its visibility, and increasing the submission rate from 32 articles in 2006 to 123 in 2007 and poised to reach 400 submissions this year, in effect representing a twelve-fold increase in the submission rate.[3] This is reflected in the increase in journal issues from 3 to 4 per year, while at the same time the article rejection rate has steadily increased from 10% in 2006 to 66% in 2008 clearly suggesting that there has been no compromise in the quality of published articles. This is also evident by the increase in basic science papers published in the journal. Generally, journals from this region receive submissions from within the region and not from other parts of the world, so the research that we publish is circumscribed by geographical location. While SJG was initially designed to disseminate local and regional literature, this aspect has vastly been superseded by the emergence of the electronic version of the journal. Presently, about 80% of the articles are submitted from outside of Saudi Arabia, with the figure having remained stable over the past three years, thus imparting a truly international flavor to the Journal. For instance, the present issue hosts articles, not just from Saudi Arabia, but also from Iran, Bangladesh, India, Turkey and Kuwait. Simultaneously, SJG has witnessed other changes that are representative of the evolving reality of the publishing world. The journal has embarked and succeeded in putting all issues from its very inception online. This important step has served investigators who have over the years published important work that was not anymore accessible or available. The journal has also invested heavily to improve visibility in many ways. In testimony of its current visibility, SJG ranks first within a Google search for “Saudi journal” indicative of journal visits online, its popularity within the region, and its overall visibility. It boasts of an international Advisory Board that reads as the whos-who in the world of gastroenterology. The present editorial board has a distinctively ‘young look’ much in line with the journals policy of encouraging a generation of young investigators. In addition, our list of reviewers has also undergone a paradigm shift with almost 80% of our reviewers now registered from outside of Saudi Arabia. Amongst other things, the quality of any journal is dependent on the involvement and interest of its reviewers.[4] In this aspect we continue to face many problems. Nothing is more frustrating to the editor than a reviewer who fails to conduct a review, leave alone a proper one, after initially agreeing to the task. Even more frustrating is the fact that authors defy the simple and basic instructions to authors when either submitting or revising their manuscripts, despite the user-friendliness of the manuscript management system. This places an immense burden on the administrative staff, depleting the journals time, resources and goodwill. Ethical misconduct continues to be a problem[5] although the mechanism in place has made the task of weeding out this problem much simpler. Eventually, a journal is recognized by the quality of its publications. While numbers count, it is quality that eventually matters. With the rising tide of research within the Middle-East, and the developing world in general, we anticipate that we will attract better articles as we move forward. Finally, our journey at SJG does not end here; it can only begin from here. Our next goal remains to get the journal indexed in the Science Citation Index (SCI) which will provide us with the ‘elusive’ impact factor. The citations received by SJG have increased over the last few years, as can be seen on the journals website (http://www.saudijgastro.com/showstats.asp?a=tc) and we are hopeful to be included in SCI. Truly, much has been done but, much more needs to be done. The real work begins now and if the passion for success can be a measure of ones achievements, then we, at SJG, are rightly poised to achieve this. As Robert Frost once said: But I have promises to keep, and miles to go before I sleep …