Omar I. Saadah

Incidence of pediatric inflammatory bowel disease in Saudi Arabia: a multicenter national study.

Background:Pediatric inflammatory bowel disease (IBD) is increasingly recognized in developing countries; however, the incidence and trend over time have not been reported. Methods:This retrospective study included children diagnosed with IBD in gastroenterology centers in the Kingdom of Saudi Arabia between 2003 and 2012. The date of birth, date and age at diagnosis, gender, and final diagnosis were collected on special forms. Clinical, laboratory, imaging, endoscopy, and histopathology results were reviewed to confirm the final diagnosis. Descriptive statistics were used to compare ulcerative colitis and Crohns disease in different age groups, and significance was assessed by the chi-square test. Incidence rates and trend over time were analyzed with the assumption of Poisson distribution. The incidence rate over time was compared in 2 periods (2003–2007 and 2008–2012). A P value of <0.05 and 95% confidence intervals were used to assess the significance and precision of the estimates. Results:A total of 340 Saudi Arabian children aged 0 to 14 years were diagnosed. The mean incidence rate per 100,000 individuals was 0.2, 0.27, and 0.47 for ulcerative colitis, Crohns disease, and IBD, respectively. Except for the 0- to 4-year age group, there was a significant increase in incidence over time. Conclusions:Although the incidence of pediatric IBD in Saudi Arabian children is lower than suggested in the Western literature, there is a significantly increasing trend over time. However, decreased trend in the younger age group over time is identified. Prospective studies will be important to identify the risk factors for IBD in different age groups.

Gastrointestinal basidiobolomycosis in a child; an unusual fungal infection mimicking fistulising Crohn's disease

BACKGROUND Gastrointestinal basidiobolomycosis is a rare disease caused by the fungus Basidiobolus ranarum. It has been reported in both children and adults. The disease mainly affects the colon and the small bowel; however, cases of the stomach, liver, pancreas, and renal system being affected have been reported. CASE REPORT A 2 year old boy presented with the following symptoms; abdominal pain, vomiting, diarrhea, fever and palpable right iliac fossa mass. Laboratory investigations revealed elevated inflammatory markers and peripheral eosinophilia. Colonoscopy showed severely inflamed mucosa of the terminal ileum, cecum and ascending colon. CT scan of the abdomen demonstrated an inflammatory mass with wall thickening of the terminal ileum and the colon. Surgical exploration demonstrated retroperitoneal mass and inflamed terminal ileum, cecum and ascending colon. Upon laparotomy, multiple internal fistulas involving the bowel loops, the urinary bladder, the right ureter and the gallbladder were observed. Further investigations using histopathology of the resected diseased bowel showed extensive necrosis, multinucleated giant cells and numerous eosinophils and large fungal hyphae surrounded by strongly eosinophilic material were seen in the tissue suggestive of B. ranarum infection. The patient responded well to treatment with voriconazole. CONCLUSION Gastrointestinal basidiobolomycosis should be considered in the differential diagnosis of every child presenting with abdominal pain, fever and palpable abdominal mass with peripheral eosinophilia. The presence of bowel inflammation and fistulas should not preclude such diagnosis.

Solitary rectal ulcer syndrome presenting as polypoid mass lesions in a young girl

Solitary rectal ulcer syndrome (SRUS) is a rare condition in children. We report a case of SRUS in an 8-year old Saudi girl who presented with recurrent rectal bleeding, intermittent mucosal prolapse, and passage of mucus per rectum. Colonoscopy revealed multiple polypoid mass lesions with histopathological features of SRUS. The polypoid variant of SRUS is very rare in children and may be confused with rectal malignant or inflammatory conditions.

Clinical Pattern of Early-Onset Inflammatory Bowel Disease in Saudi Arabia: A Multicenter National Study.

Background:The objectives of this multicenter national study were to compare the clinical phenotype of early-onset inflammatory bowel disease (IBD) (EO-IBD) with IBD in older children and to examine whether there is any variability in consanguinity rate and familial aggregation in EO-IBD compared with later onset IBD. Methods:A retrospective analysis was performed on children aged 0 to 14 years with IBD in 17 centers located in geographically distinct regions in Saudi Arabia, from 2003 to 2012. Data of patients with EO-IBD (0 to <6 yrs) were compared with those with later onset IBD (6–14 yrs). Moreover, we evaluated differences in clinical pattern of infantile or toddler onset IBD subgroup (0–3 yr) as compared with those presenting in older children. Results:Of 352 IBD patients identified during the 10-year study period, 76 children (21.6%) younger than 6 years were diagnosed with IBD. Among the Crohns disease (CD) group, infantile or toddler onset CD subgroup showed a more frequent isolated colonic involvement (L2) than later-onset group (57% versus 20%; P = 0.002). Positive family history was significantly more common in the infantile or toddler onset ulcerative colitis subgroup (29.4% versus 4.2% in later onset ulcerative colitis; P < 0.0001). The consanguinity rate was significantly higher in the infantile or toddler onset CD subgroup as compared with later onset CD group (57.1% versus 25.3%; P = 0.04). Conclusions:In conclusion, EO-IBD exhibits a unique clinical phenotype with a strikingly higher familial aggregation in early-onset ulcerative colitis. Our data suggest a significant genetic impact on the onset of CD in the very young children.

Eosinophilic Esophagitis in Children from Western Saudi Arabia: Relative Frequency, Clinical, Pathological, Endoscopic, and Immunological Study

Background and Purpose. Eosinophilic esophagitis (EE) is an evolving allergic disease with an accelerated incidence. The purpose of this study was to delineate the relative frequency and clinicopathological characteristics of EE in children from western Saudi Arabia. Methods. Children with EE were studied retrospectively between October 2002 and December 2011 at King Abdulaziz University Hospital and International Medical Center. Results. The relative frequency of EE was 0.85% of 2127 upper gastrointestinal endoscopies performed during the study period. Eighteen patients were identified with EE. The median age was 8.6 years (range, 1.5–18 years). Thirteen (72.2%) were males. Dysphagia and vomiting were the most common symptoms. Ten (55.6%) children had history of atopy. Testing for food allergy by skin prick test was positive in 11 (61.1%). The most common endoscopic abnormalities were mucosal longitudinal furrow and loss of vascular pattern followed by patchy specks and strictures. The histopathological findings included increased intraepithelial eosinophils, eosinophilic degranulation, lamina propria fibrosis, and eosinophilic microabscesses. Treatment was initiated by swallowed topical corticosteroids in 12 (66.7%) and oral prednisolone in 6 (33%) patients, followed by low dose of topical corticosteroids and dietary elimination. Conclusions. Eosinophilic esophagitis is an uncommon but evolving problem. A high index of suspicion is required for early identifications and intervention to avoid possible complications.

Entecavir treatment of children 2-16 years of age with chronic hepatitis B infection.

BACKGROUND AND STUDY AIMS Childhood acquired chronic hepatitis B is associated with a significant lifetime risk of developing cirrhosis or hepatocellular carcinoma. Our objective in this study was to report retrospectively the response to treatment with Entecavir in 8 children with chronic hepatitis B followed at the King Abdulaziz University Hospital, Jeddah, Saudi Arabia. PATIENTS AND METHODS This study is an observational hospital based chart review of children and adolescents with chronic hepatitis B treated with entecavir at the King Abdulaziz University Hospital, Jeddah, Saudi Arabia in the period between June 2007 and July 2011. RESULTS Half of the studied group was males, and the median age at the time of treatment was 4.8 years (range, 2.6-15). All subjects displayed infection with HBV genotype D and all were HBeAg positive. Half of the patients had been previously treated with lamivudine, while the remaining half was treatment naïve patients. The mean ALT±SD was 84.9±34.7IU/L (range, 46-133) and the mean HBV DNA was 5.01×10(8)±5.7×10(8) IU/mL (range, 5.5×10(7)-1.3×10(9)). Patients were treated with a daily oral dose of 0.5mg entecavir, and the mean duration of treatment was 23.8±11.9 months, (range 14.9-44.7 months). HBV DNA suppression of more than 2 log(10) was achieved in all patients. HBV DNA was undetected in 37.5%, with ALT normalization in 87.5% and lastly HBeAg seroconversion and loss occurred in 37.5%. No adverse side effects were observed during the treatment with entecavir. CONCLUSION We conclude from this limited data that 37.5% of children treated with entecavir achieved HBeAg loss and seroconversion with no side effects observed during treatment period, however long term safety and efficacy in children should be demonstrated through a multicenter study, enrolling large number of patients.

Perceptions and knowledge regarding antimicrobial stewardship among clinicians in Jeddah, Saudi Arabia

Objectives: To understand the perceptions, attitude, and prescribing practices of clinicians regarding antimicrobial resistance (AMR). Methods: A multidisciplinary cross-sectional study comprising 447 clinicians of university, public, and private hospitals of Jeddah, Saudi Arabia was carried out from August to October 2014 using a self-administered questionnaire. Results: Interestingly, 33% of the general physicians yielded to patient/parent’s demand for the choice of antimicrobials (AMs) as compared with only 13.2% of the residents, and 4.3% of the specialists. In addition, expensive AMs are more often prescribed by the general physician (70.4%) in comparison with 26.4% residents and 30.4% of the specialists. However, no significant differences were observed between the knowledge and perceptions regarding the current scope of AM agents, as well as their use and misuse. Furthermore, dependability of specialist and residents seems to be significantly higher than general physicians on pocketbooks and smartphone for AM education sources. Conclusion: This study revealed that despite a clear concept of AMR, general physicians lacks consistency in prescribing aptitude and use of effective educational resources, while all respondents lacks dedication to follow the guidelines of AM use. This highlights the requirement of AM stewardship with decisive objective of reduction in AMR.

Congenital glucose-galactose malabsorption: a descriptive study of clinical characteristics and outcome from Western Saudi Arabia.

BACKGROUND AND STUDY AIMS Congenital glucose galactose malabsorption (CGGM) is a rare autosomal recessive disorder caused by a defect in the sodium-coupled transport of glucose and galactose across the intestinal brush border presenting with neonatal diarrhoea. The aim of this study was to report the clinical and laboratory characteristics of patients with CGGM from the Western Saudi Arabia. PATIENTS AND METHODS This is a retrospective review of CGGM patients in three major hospitals in the city of Jeddah, Saudi Arabia, namely King Abdulaziz University Hospital, King Faisal Specialist Hospital and Research Centre, and Maternity Children Hospital in the period between November 2001 and October 2011. RESULTS Twenty-four patients with CGGM have been described. The median age at diagnosis was 4.5 months. Twelve (50%) were males. Sixteen (66.7%) were Saudi and 8 (33.3%) were non Saudi (5 Arabs and 3 Asians). Parents of 21 patients were consanguineous. Nine (37.5%) had affected siblings with CGGM. All presented with diarrhoea resulted in dehydration. Hypernatremia was seen in 7 (29.2%) patients, renal tubular acidosis in 4 patients. Renal stones and nephrocalcinosis were detected in 3 (12.5%) patients at 8 months, 12 months and 7 years, respectively. The median follow up was 41.6 months. All but three demonstrated normal weight gain. Five patients reported one or more symptoms of bloating (n=3), diarrhoea (n=3) and abdominal pain (n=1) during follow up. All had normal development and none had neurological complications secondary to dehydration. CONCLUSION Early recognition and management of this condition are crucial to prevent consequences of dehydration and death.

Haematological manifestations of arthrogryposis-renal dysfunction-cholestasis (ARC) syndrome: a case report.

Arthrogryposis multiplex congenita, renal dysfunction, and cholestasis (ARC) syndrome is a rare, fatal, multisystem disorder. Bleeding problems, which occur spontaneously and post organ biopsies, have been reported in these patients. We report the case of an infant who had life-threatening spontaneous nasal bleeding. A detailed assessment of her platelet function and morphology is presented.

Hepatic-associated immunoglobulin-A nephropathy in a child with liver cirrhosis and portal hypertension.

Hepatic-associated immunoglobulin A (IgA) nephropathy is a relatively common condition that occurs in adults with liver cirrhosis and portal hypertension. However, it is rare in children. This condition is characterized by the deposition of IgA in the renal glomeruli. The present report describes a 14-year-old boy with cryptogenic liver cirrhosis and portal hypertension who presented with hematuria and proteinuria associated with histological changes of IgA nephropathy.