Iqbal Siddique

Palliation of malignant dysphagia and fistulae with coated expandable metal stents: Experience with 101 patients

BACKGROUND Insertion of coated expandable esophageal stents is the preferred endoscopic palliative treatment for malignant dysphagia and digestive-respiratory fistulae. METHODS One hundred one patients with malignant dysphagia and digestive-respiratory fistulae, 83 due to esophageal cancer and 18 due to metastatic disease, underwent placement of a coated expandable metal stent. Thirteen patients had a digestive-respiratory fistula. The stricture location (99 patients) was proximal in 11, mid in 29, distal in 37, and at the gastroesophageal junction in 24. The endoscopic appearance was exophytic in 80, infiltrative in 19, single ulcer in 1, and normal in 1. The mean stricture length was 6.7 cm. RESULTS Initial stent placement was successful in 100 patients; a second stent was required in 1. The median dysphagia grade improved from 3.6 to 1.4 and sealing-off of the digestive-respiratory fistula was successful in all cases. The overall complication rate was 37.9%. Life-threatening complications occurred in 7.9%. There were no procedure-related deaths. During a mean follow-up of 201 days, 99 patients died-none from stent-related problems. CONCLUSIONS This large series confirms the efficacy of the coated metal expandable stent in the palliation of malignant dysphagia and digestive-respiratory fistula with an acceptable complication rate.

Sampling variability on percutaneous liver biopsy in patients with chronic hepatitis C virus infection.

Background: Sampling variability on liver biopsy has been demonstrated in a variety of liver diseases. The objective of this study was to determine whether sampling variability exists on percutaneous liver biopsy in patients with chronic HCV infection. Methods: Two separate tissue samples were obtained from the right lobe of the liver, through a single skin puncture, in 29 patients (22 M, mean age 43.4 ± 8.1 years) with chronic HCV infection. The biopsies were assessed using a descriptive histological reporting system and Knodells Histological Activity Index (HAI) and compared for differences in necroinflammatory activity (grade) and fibrosis (stage). Results: Thirteen (44.8%) patients had a difference of ≥1 grade between the 2 biopsies on the descriptive system and 13 differed by ≥1 stage. On the HAI, 20 (69.0%) patients had a difference of ≥2 in the necroinflammatory activity score and 10 (34.5%) had a difference of ≥4; whereas, 11 (38.0%) patients had a difference of ≥1 in the fibrosis score and 6 (20.7%) had a difference of ≥2. The mean difference between the two sets of biopsies was 2.4 ±2.1 (range 0–7) for the necroinflammatory activity and 0.6 ±0.9 (range 0–3) for fibrosis. Spearmans correlation coefficient (r) was moderate for both necroinflammatory activity (r = 0.53, P < 0.01) and fibrosis (r = 0.62, P < 0.0001). Conclusions: Sampling variability exists on percutaneous liver biopsy in patients with chronic HCV infection and should be taken into consideration when decisions regarding prognosis and therapy are made based on biopsy, and when defining histological response to antiviral regimens.

The role of choledochoscopy in the diagnosis and management of biliary tract diseases

BACKGROUND The diagnosis and management of biliary tract disorders in certain cases may be incomplete without direct visualization of the bile ducts. METHODS We report our experience of 61 choledochoscopies (33 women, 27 men, mean age 44.6 years). Twenty patients had previously undergone orthotopic liver transplantation. All except two choledochoscopies were performed via the transpapillary route. Indications included suspected large bile duct stones in 18 patients, anastomotic strictures in 16, abnormal cholangiograms in 5, elevated liver function tests in 7, suspected cholangiocarcinoma in 4, occluded biliary metallic stent in 4, hemobilia in 4, primary sclerosing cholangitis in 2 and ischemic bile duct injury in 1 patient. RESULTS Choledochoscopy confirmed the anticipated diagnosis in 36 of 61 (59%) patients. Importantly, it provided additional unsuspected diagnostic information in 18 of the 61 (29.5%) patients. In addition, for patients in whom standard cholangiography was deemed abnormal, choledochoscopy demonstrated normal results in 7 (11.4%) patients. Fifty-two choledochoscopies were performed with therapeutic intentions, and the procedure was helpful in providing targeted treatment in 27 (44.2%) patients. CONCLUSIONS Choledochoscopy is a safe and useful endoscopic modality that can provide specific diagnoses and direct treatment in various biliary tract diseases. The additional information provided by choledochoscopy may change overall patient management and outcome.

Dental x-rays and the risk of thyroid cancer: A case-control study

Abstract The thyroid gland is highly susceptible to radiation carcinogenesis and exposure to high-dose ionising radiation is the only established cause of thyroid cancer. Dental radiography, a common source of low-dose diagnostic radiation exposure in the general population, is often overlooked as a radiation hazard to the gland and may be associated with the risk of thyroid cancer. An increased risk of thyroid cancer has been reported in dentists, dental assistants, and x-ray workers; and exposure to dental x-rays has been associated with an increased risk of meningiomas and salivary tumours. Methods. To examine whether exposure to dental x-rays was associated with the risk of thyroid cancer, we conducted a population-based case-control interview study among 313 patients with thyroid cancer and a similar number of individually matched (year of birth ± three years, gender, nationality, district of residence) control subjects in Kuwait. Results. Conditional logistic regression analysis, adjusted for other upper-body x-rays, showed that exposure to dental x-rays was significantly associated with an increased risk of thyroid cancer (odds ratio = 2.1, 95% confidence interval: 1.4, 3.1) (p=0.001) with a dose-response pattern (p for trend <0.0001). The association did not vary appreciably by age, gender, nationality, level of education, or parity. Discussion. These findings, based on self-report by cases/controls, provide some support to the hypothesis that exposure to dental x-rays, particularly multiple exposures, may be associated with an increased risk of thyroid cancer; and warrant further study in settings where historical dental x-ray records may be available.

PREVALENCE OF VIRAL MARKERS AMONG FIRST-TIME ARAB BLOOD DONORS IN KUWAIT

BACKGROUND: The aim of this study was to assess the effect of blood donation modes on the prevalence of viral markers among Arab first‐time blood donors in Kuwait.

Role of Na+/H+ exchanger isoform-1 in human inflammatory bowel disease.

BACKGROUND Na+/H+ exchanger (NHE) is responsible for a net uptake of sodium chloride and water from the gastrointestinal tract and maintains electrolyte and water homeostasis. However, its status in human inflammatory bowel disease such as ulcerative colitis (UC) and Crohns disease (CD) remains poorly understood. OBJECTIVES To investigate the role of NHE-1 isoform in human CD and UC. METHODS Expression of NHE-1 protein and messenger ribonucleic acid and sodium pump activity were examined in the colonic biopsy samples taken from UC (n=11) and CD (n=13) patients using enhanced chemiluminescence-Western blot analysis, reverse transcription polymerase chain reaction and spectrophotometry. Subjects presenting with abdominal pain and endoscopically normal colon served as normal controls (n=11). Myeloperoxidase (MPO) activity and histology were performed to confirm tissue inflammation. RESULTS MPO activity increased significantly (P<0.05) in both UC and CD patients compared with the normal controls. Parallel to MPO activity profile, there was also a significantly higher infiltration of inflammatory cells in both cases. P-nitrophenylphosphatase activity, a marker of the sodium pump, remained unchanged in CD but increased significantly (P<0.05) in UC compared with the normal controls. On the contrary, the level of NHE-1 protein and messenger ribonucleic acid was significantly decreased (P<0.05) in both cases, whereas the internal control, a-actin remained unaltered. CONCLUSIONS These findings demonstrate a transcriptionally regulated suppression of NHE-1 in both UC and CD. This NHE-1 suppression may reduce an uptake of sodium chloride and water from the inflamed colonic lumen and thus contribute to diarrhea and neuromuscular alterations in these conditions.

Diagnosis of Helicobacter pylori: improving the sensitivity of CLOtest by increasing the number of gastric antral biopsies.

Background and Goal The rapid urease CLOtest is commonly used during endoscopy to diagnose the presence of Helicobacter pylori. The aim of this study was to determine whether the sensitivity of the CLOtest can be improved by increasing the number of gastric antral biopsies from 1 to 4. Methods The study included 100 adult patients who were referred for upper gastrointestinal endoscopy and tested positive for H. pylori infection on 13C urea breath test (“gold standard”). These 100 patients were then randomly divided into 4 equal groups (groups 1 to 4), and underwent an upper gastrointestinal endoscopy. Patients in group 1 had 1 gastric antral biopsy during endoscopy, whereas those in groups 2, 3, and 4 had 2, 3, and 4 biopsies, respectively. The biopsies were placed in the rapid urease CLOtests, which were incubated at room temperature for up to 24 hours, and read for positive results at 1, 6, and 24 hours. Results About half of the patients (52%) had a positive CLOtest in group 1, compared to 68% in group 2, 76% in group 3, and 96% in group 4 (group 1 vs. 4 P<0.01). After 1 hour of incubation 96% of the patients in group 4 had a positive CLOtest, compared to 40% in group 3, 12% in group 2, and 4% in group 1. Conclusions Increasing the number of gastric antral biopsies from 1 to 4 significantly improves the sensitivity of the CLOtest, eliminates sampling error, and hastens the time needed by the test to become positive for the diagnosis of H. pylori infection.

Transjugular Liver Biopsy in Patients with EndStage Renal Disease

PURPOSE To assess the efficacy and safety of transjugular liver biopsy (TJLB) in patients with end-stage renal disease (ESRD) who are undergoing hemodialysis treatment. MATERIALS AND METHODS Forty-six consecutive patients with liver disease who were undergoing hemodialysis were included in this study. An 18-gauge Tru-cut transjugular needle with a 20-mm throw was used to obtain liver tissue. All procedures were performed under fluoroscopic guidance. A single pathologist reviewed the biopsy specimens and assessed the size of fragments, number of portal tracts, and adequacy of the specimens for histologic diagnosis. All complications were recorded. The results were compared with the outcomes of percutaneous liver biopsy carried out at our institution in 32 patients with ESRD. RESULTS TJLB and percutaneous biopsy techniques yielded adequate specimens for histologic diagnosis in all patients. The mean length of the largest fragments of tissue obtained via the transjugular and percutaneous routes were 16 mm +/- 4 and 14 mm +/- 3, respectively (P = NS). There were no major complications among patients who underwent TJLB. Percutaneous liver biopsy was complicated by hemorrhage in four of 32 patients (12%), three of whom required blood transfusion. CONCLUSION TJLB is an effective and safe technique to obtain liver tissue in patients with ESRD and is associated with a lower complication rate than percutaneous liver biopsy.

Suppression of Na+/H+ exchanger isoform-3 in human inflammatory bowel disease: Lack of reversal by 5′-aminosalicylate treatment

Objective. Na+/H+ exchanger isoform 3 (NHE-3) is responsible for net uptake of NaCl and water from the gastrointestinal (GI) tract. However, its status in human inflammatory bowel diseases (IBDs) such as ulcerative colitis (UC) and Crohns disease (CD) remains poorly understood. The aim of this study was to investigate the underlying mechanism of NHE-3 isoform expression and its modulation by 5′-aminosalicylate in human CD and UC. Material and methods. Subjects were divided into three groups: 1) controls; 2) untreated/new IBD cases (n=13) and 3) 5′- aminosalicylate-treated IBD patients (n_13). Subjects presenting with abdominal pain but with endoscopically normal colons served as normal controls. Inflammation was confirmed by the level of myeloperoxidase (MPO) activity, malondialdehyde (MDA) concentrations and by histologic evaluation. Expressions of NHE-3 protein and mRNA, sodium pump activity and IL-1β and TNF-α mRNA were estimated in the colonic biopsies using ECL-Western blot analysis, reverse transcription-polymerase chain reaction (RT-PCR) and enzyme assays. Results. The level of NHE-3 protein and sodium pump activity was reduced (p<0.05) in both the untreated and treated CD and UC patients. NHE-3 mRNA was reduced only in CD patients but not in those with UC. The treatment reversed the symptoms, but levels of MPO activity, MDA concentration, IL-1β, TNF-α and infiltration of inflammatory cells remained high with the exception of IL-1β mRNA in the treated patients. Conclusions. NHE-3 suppression is regulated differentially in CD and UC, which together with suppression of sodium pump activity will reduce NaCl and water uptake from the colonic lumen. These findings suggest a role of TNF-α in the regulation of NHE-3 expression in IBD.

Interferon-Alpha in Combination with Ribavirin for the Treatment of Chronic Hepatitis C in Patients with Persistently Normal Aminotransferase Levels

Background and Aims: A substantial proportion of patients with chronic hepatitis C virus infection have persistently normal serum transaminase levels. The aim of this study was to assess the efficacy and safety of interferon plus ribavirin combination therapy in this population. Methods: In this prospective open trial 152 patients with biopsy-proven chronic hepatitis C were enrolled, 32 of whom had persistently normal alanine aminotransferase levels (group A). The remaining 120 patients served as a comparison (group B). Patients were treated for 12 months with 4.5 million units of interferon-α2a thrice weekly in combination with ribavirin 1,000 or 1,200 mg daily. They were followed up for at least 6 months after therapy. Serum hepatitis C RNA was detected by polymerase chain reaction and quantified by a branched DNA assay. Results: At the end of treatment, 12 (37.5%) and 48 patients (40%) were negative for HCV-RNA in groups A and B, respectively (p = 0.33). After 24 weeks of follow-up, 9 patients (28%) from group A and 36 patients (30%) from group B were still HCV-RNA negative (p = 0.4). Treatment was well tolerated by both groups. There were no alanine transferase elevations among group A patients during therapy. Conclusion: Interferon-ribavirin combination therapy was safe and induced a sustained virologic response in a significant proportion of patients with chronic hepatitis C and repeatedly normal serum transaminase levels.