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Background: Screening endoscopy for varices may be deferred when the calculated EVendo score is ≤3.90. This novel score has not been validated in an external cohort. This study aimed to assess the performance of the EVendo score and compare it with the Baveno VI criteria., Methods: We identified and calculated this score in all cirrhotic patients who underwent screening endoscopy for the first time with laboratory tests and liver stiffness measurements within 6 months of the endoscopy date., Results: In total, 103 patients were included. An EVendo score of ≤3.90 identified patients with no gastroesophageal varices (GEV) and varices needing treatment (VNT) with sensitivities of 82% and 83% and specificities of 57% and 34%, respectively. The negative predictive value for VNT was 94%. A comparison with the Baveno VI criteria in Child-Turcotte-Pugh-A patients showed spared endoscopy and missed VNT rates with EVendo score cutoffs of ≤3.9 and ≤4.5 and the Baveno VI criteria of 25%, 33%, and 16.6% and 1.7%, 1.7%, and 0%, respectively., Conclusions: EVendo score is reliable in clinical practice for predicting GEV and VNT. The number of spared endoscopies was higher than that with the Baveno VI criteria; however, there were more missed VNT cases., Competing Interests: None

Background/aim: Gallstone disease (GD) and nonalcoholic fatty liver disease (NAFLD) are associated with metabolic syndrome. Despite the benign nature of NAFLD, 10% of patients may develop advanced fibrosis and cirrhosis. We aimed to identify the prevalence and factors associated with NAFLD among GD patients in the Saudi population., Patients and Methods: This is a single-center, observational cohort study that included patients seen in general surgery clinics at our institution from 2011 to 2017. All liver biopsies were taken at the same time as the cholecystectomy. Demographical and clinical data were prospectively collected from the study population., Results: Of the 301 GD patients in the study, 15% had a normal body mass index (BMI), 29% were overweight, and 56% were obese. There were 143 (47.8%) patients with NAFLD, of which 125 (41.8%) showed steatosis and 18 (6%) had nonalcoholic steatohepatitis. There was a significant positive correlation between NAFLD and age (r = 0.243; P < 0.0001), and BMI (r = 0.242; P < 0.0001). Obese patients with BMI 30-40 kg/m [2] were 2.403 (P = 0.039) more likely to have NAFLD compared with normal BMI patients, and this value increased to 6.145 (P = 0.002) in patients with BMI >40 kg/m [2] . Additionally, patients with T2DM were 2.839 times (P = 0.015) more likely to have NAFLD compared with those who did not., Conclusions: The prevalence of NAFLD among GD patients is high. High BMI and diabetes are independent factors associated with NAFLD in GD patients. The results suggest that there may be a need for routine liver biopsy in selected patients during cholecystectomy., Competing Interests: None

Background/aims: Middle Eastern countries, including Saudi Arabia to some extent, are endemic for chronic hepatitis B (CHB) infection which could be associated with high mortality and comorbidities risk. However, limited data characterizing this CHB population exists. Our aim was to characterize and compare CHB patients in 2015 with those in 2010 and 2012 in Saudi Arabia., Patients and Methods: We conducted and compared three cross-sectional analyses of adult patients with CHB defined as either positive hepatitis B surface antigen or documented CHB history in 2010, 2012, and 2015. Data were accessed from the multicenter Systematic Observatory Liver Disease Registry (SOLID)., Results: A total of 765 CHB patients were identified in 2010 (n = 274), 2012 (n = 256), and 2015 (n = 235). Median age was significantly higher in 2015 (47 years) compared to 2010 and 2012 (42 years;P < 0.05). The proportions of patients with hepatocellular carcinoma (range 1-12%) and cirrhosis (range 5-23%) were significantly higher in 2015 compared to 2010 and 2012 (P < 0.05). Compared to 2010, patients in 2015 had significantly (P < 0.05) higher prevalence of coronary artery disease (10% vs. 4%) and hyperbilirubinemia (18% vs. 9%). Although not significant, there was a numerical increase in 2015 in chronic kidney disease (9% vs. 7% in 2010;P= 0.559) and hepatic steatosis (32% vs. 25% in 2010;P= 0.074). Significantly more patients in 2015 (P < 0.05) were treatment experienced (23% vs. 5% in 2010/2012) and switched treatment (17% vs. 1-2% in 2010/2012)., Conclusions: Between 2010 and 2015, the CHB population in Saudi Arabia had significantly aged and was more likely to develop liver disease sequelae and other comorbidities., Competing Interests: None

Background/aims: Hepatitis B virus (HBV) continues to be one of the most important viral pathogens in humans. Surface (S) protein is the major HBV antigen that mediates virus attachment and entry and determines the virus subtype. Mutations in S gene, particularly in the "a" determinant, can influence virus detection by ELISA and may generate escape mutants. Since no records have documented the S gene mutations in HBV strains circulating in Saudi Arabia, the current study was designed to study sequence variation of S gene in strains circulating in Saudi Arabia and its correlation with clinical and risk factors., Patients and Methods: A total of 123 HBV-infected patients were recruited for this study. Clinical and biochemical parameters, serological markers, and viral load were determined in all patients. The entire S gene sequence of samples with viral load exceeding 2000 IU/mL was retrieved and exploited in sequence and phylogenetic analysis., Results: A total of 48 mutations (21 unique) were recorded in viral strains in Saudi Arabia, among which 24 (11 unique) changed their respective amino acids. Two amino acid changes were recorded in "a" determinant, including F130L and S135F with no evidence of the vaccine escape mutant G145R in any of the samples. No specific relationship was recognized between the mutation/amino acid change record of HBsAg in strains in Saudi Arabia and clinical or laboratory data. Phylogenetic analysis categorized HBV viral strains in Saudi Arabia as members of subgenotypes D1 and D3., Conclusion: The present report is the first that describes mutation analysis of HBsAg in strains in Saudi Arabia on both nucleotide and amino acid levels. Different substitutions, particularly in major hydrophilic region, may have a potential influence on disease diagnosis, vaccination strategy, and antiviral chemotherapy.

Liver transplantation is universally accepted as a "cure" procedure, and yet is not universally applicable for the treatment of end-stage liver diseases (ESLD) because of the shortage of donors, operative complications, risk of rejection, and high cost. Bioartificial liver device is an option to temporarily improve the liver function and to bridge the patients to liver transplantation. However, bioartificial liver device has many problems in clinical application, such as hepatocyte allograft rejection and maintenance of hepatocyte viability and function. Another therapeutic option is stem cell transplantation. There are two broad types of stem cells: Embryonic stem cells and adult stem cells. The latter are sourced from bone marrow (BM), adipose tissue, and blood. This review will concentrate on BM-derived cells. BM-derived cell transplantation, although not ideal, is theoretically an optimal modality for the treatment of ESLD. Autologous BM-derived cells have no graft rejection, have the capability of regeneration and self-renewal, and are multipotent stem cells that can differentiate into a variety of cell types which include hepatocytes. The pathway from BM-derived cell to hepatocyte is well documented. The present review summarizes the delivery routes of BM-derived cells to the liver, the evidences of engraftment of BM-derived cells in the liver, and the possible mechanisms of BM-derived cells in liver repair and regeneration, and finally, updates the clinical applications.

Objective: A review of published data addressing hepatic histopathological, metabolical, and functional changes following gastric banding, sleeve gastrectomy, gastric bypass surgery, and biliopancreatic with duodenal switch surgeries on nonalcoholic fatty liver disease (NAFLD). NAFLD is currently the most common chronic liver disease. Owing to the strong relationship between obesity and NAFLD, the idea of weight reduction as a method to treat NAFLD has rapidly emerged. Bariatric surgery has proved to be the most efficient method for weight reduction; hence, their beneficial effects on NAFLD have been evaluated by several studies. A literature review of published data was performed during the years 2012-2014 using PubMed with the following key words: Bariatric, NAFLD, steatosis, sleeve gastrectomy, gastric bypass, gastric banding, biliopancreatic diversion with duodenal switch, obesity, and insulin resistance (IR). Exclusion criteria were non-English articles and inherited NAFLD, pregnancy-induced NAFLD, and children. The majority of published data are in favor of indicating that bariatric surgeries improve the histologic and metabolic changes associated with NAFLD. The suggested mechanisms are: The reversal of IR, reduction of inflammatory markers, and improved histological features of NAFLD. Accordingly, bariatric surgeries are potentially one of the future methods in treating patients with morbid obesity and NAFLD. However, some questions remain unanswered, such as whether timing of surgery, type of surgery most effective, and whether bariatric surgeries are capable of curing the disease. Long-term and well-designed prospective studies are needed to address these issues.

Background/aim: To assess the correlation between serum HBsAg titers and hepatitis B virus (HBV) DNA levels in patients with hepatitis B envelop antigen-negative (HBeAg -ve) HBV genotype-D (HBV/D) infection., Patients and Methods: A total of 106 treatment- naïve, HBeAg -ve HBV/D patients were included; 78 in the inactive carrier (IC) state and 28 in the active hepatitis (AH) stage. HBV DNA load and HBsAg titers were tested using TaqMan real-time polymerase chain reaction (PCR) and automated chemiluminescent microparticle immunoassay, respectively., Results: The median (range) log10 HBsAg titer was significantly lower in the IC group compared with AH group, 3.09 (-1 to -4.4) versus 3.68 (-0.77 to 5.09) IU/mL, respectively; P < 0.001. The suggested cutoff value of HBsAg titer to differentiate between the two groups was 3.79 log10 IU/mL. In addition, there was a significant positive correlation between HBsAg and HBV DNA levels in the whole cohort, AH, and IC groups (r = 0.6, P < 0.0001; r = 0.591, P = 0.001; and r = 0.243, P = 0.032, respectively)., Conclusion: Serum HBsAg titers may correlate with HBV DNA in treatment-naïve HBeAg -ve HBV/D patients, and supports the use of HBsAg levels in clinical practice as a predictor of serum HBV DNA levels.

Background and Aims: Complementary alternative medicine (CAM) covers many types of treatments and procedures that are usually not included in conventional medicine and are used in addition to physician-prescribed drugs to "complement" treatment. Although liver disease is prevalent in Saudi Arabia, not much is known about CAM use among Saudi liver disease patients. Thus, this study aimed to assess the prevalence of CAM use in these patients and their attitudes toward it., Materials and Methods: Patients were recruited randomly from a tertiary care hepatology clinic at King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia from February 4 to March 20, 2012. A four-page questionnaire was used to interview patients., Results: Of all the 232 participants surveyed, 55.6% have used or are using CAM to treat their liver disease with 45.0% of CAM users stating that they believe it has a positive effect on their treatment. Honey was the most used CAM treatment among the participants (39.0%). Herb use was represented by 31.8% of all users, while 13.5% used bloodletting as a treatment. Cautery was the least used CAM method (3.4%). Nearly 76.6% of CAM users were satisfied with using alternative treatments to help control their disease. Nearly 69.4% of users and nonusers stated that they believe CAM treatments to have numerous beneficial effects. Nearly 60.5% of CAM users stated that their physician had no knowledge of their CAM use. Of the factors included in linear multivariate regression analysis (including: Age, gender, and family CAM use, among other socioeconomic factors) only family CAM use was considered a significant independent factor affecting participants CAM use (Beta = 0.582, 95% CI: 0.372-0.754, P = 0.0001)., Conclusion: More than half of the patients have reported CAM use. Overall, more than two-thirds of the entire sample believed that CAM treatments have numerous health benefits.

Some 400 million people worldwide are currently infected with the hepatitis B virus (HBV), and the infection is common in the Middle East. Another 170 million people around the globe presently live with chronic hepatitis C virus (HCV) infection. Both HBV and HCV represent a worldwide epidemic. Despite significant decline in the prevalence of HBV and HCV infection in Saudi Arabia, these viral diseases cause significant morbidity and mortality, and impose a great burden on the country's healthcare system. On the other hand, Saudi epidemiology studies have shown that the hepatitis A virus seroprevalence in the country has reduced considerably over the past two decades. The progress in mapping the epidemiological pattern of viral hepatitis in Saudi Arabia has not only aided our understanding of the disease, but has also exposed the small but relevant gaps in our identification of the intricate details concerning the disease's clinical expression. In this review, we aim to document the timeline of viral hepatitis epidemiology in Saudi Arabia, while summarizing the relevant published literature on the subject.

Background/aim: Some reports in the literature have linked interferon therapy for the treatment of hepatitis C (HCV) with hearing loss. The aim of this study has been to examine the effects of interferon therapy on hearing of patients treated for HCV., Patients and Methods: Patients were recruited according to preset inclusion criteria from two centers. All patients received standard dose pegylated interferon (PEG-IFN a-2b or a-2a) plus ribavirin (RBV). All patients had pure-tone audiometry (PTA), tympanogram and distortion-product otoacoustic emission (DPOAE) before treatment, three months after initiation of treatment, and three months after completion of treatment., Results: Twenty one patients were prospectively recruited. The mean age was 45.7 years. The male to female ratio was 1.1:1. The mean PTA was 15.9 ± 5.3 before treatment, 17.4 ± 6.1 during treatment and 16.5 ± 5.1 after treatment. The differences between pre and mid, pre and post, as well as mid and post were not significantly different (P>0.05) in all audiological assessments., Conclusions: Our results indicate that PEG-IFN\RBV therapy does not have any impact on the hearing thresholds of patients with HCV.

Hepatitis C is a systemic disease that has many extrahepatic manifestations in addition to hepatic inflammation and fibrosis, some of which may result in a poor health-related quality of life (HRQOL). Fatigue is perhaps the most frequent and disabling extrahepatic symptom of hepatitis C virus (HCV), reported in almost one-half of all chronically infected individuals. Many other factors are associated with a poor quality of life in patients with HCV, including a number of physical and psychological factors. The objective of this article is to review the association between HCV and impaired HRQOL due to fatigue and psychological disturbances.

Background: Hepatocellular carcinoma (HCC) is the second commonest cancer affecting males and the eighth most common one affecting females in Saudi Arabia. Transarterial chemoembolization (TACE) is currently considered the first line therapy for multifocal HCC in selected patients., Objective: To evaluate HCC response to TACE based on triphasic computerized tomography (CT) of the liver obtained 6 weeks after the procedure., Materials and Methods: A retrospective chart review of 15 patients who underwent TACE in King Khalid University Hospital for unresectable HCC. Patients were staged according to the Child-Pugh, Okuda, and CLIP scoring systems. The first triphasic CT of the liver after TACE was evaluated for Lipiodol uptake and interval change in tumor burden., Results: The mean age was 63 years (40-82), 10 were males (66.7%), and five were females. About 11 patients had cirrhosis (73.3%). Eight patients (53.3%) were Child-Pugh class A while seven (46.7%) were Child-Pugh class B. One patient died and two were lost to follow up. Four patients had a complete response to TACE (26.7%), two had a partial response (13.3%), five showed no change (33.3%) and none showed progression of disease. Tumoral Lipiodol uptake in five patients was> 75% (33.3%), in two 75-50% (13.3%) while in four patients it was < 50% (26.7%)., Conclusion: Our results show that TACE is an effective method of reducing the tumor burden in selected patients with unresectable HCC.

Objective: To identify laboratory predictors of advanced fibrosis in Saudi Arabian patients with hepatitis B and C., Materials and Methods: Histopathology reports were obtained on all patients who had liver biopsy in the last 5 years, and relevant laboratory data were collected., Results: A total of 328 patients (246 with hepatitis C and 82 with hepatitis B) were included. With logistic regression analysis, four factors were found to be the best predictors of fibrosis, namely, platelet count, ALT, AST and GGT levels. An equation for calculating the risk of advanced fibrosis was developed. The model had a sensitivity of 62%, a specificity of 92.4% and an overall accuracy of 84%., Conclusion: Platelet count, ALT, AST and GGT levels were found to be the best predictors of advanced fibrosis on liver biopsy in Saudi patients with chronic hepatitis B and C. An equation was developed that helps in calculating this risk.

Background: Autoimmune hepatitis (AIH) is a relapsing inflammatory disease of the liver of unknown cause. Little is known about AIH in Saudi Arabia., Objectives: Our aim is to 1) identify the special clinical or histological features in our patients, 2) describe the initial response to immunosuppressive therapy and long term relapse, 3) identify clinical and laboratory predictors of response to therapy, and 4) examine the utility of laboratory markers (platelet count, AST/ALT ratio, and the AST to platelet ratio index (APRI score) in predicting the presence of advanced fibrosis., Methods: Patients were identified using a computer database. Patients responding to initial therapy were compared with patients who did not respond in terms of laboratory and histology parameters. The utility of three fibrosis markers/models were then examined., Results: Thirty-nine patients with AIH were included in this analysis. The mean age was 45.4; 65% of patients were females. Mean ALT at presentation was 268 U/L and AST was 277 U/ L. GGT level was found to be the only statistically significant laboratory or histopathological parameter difference between responders and non-responders. Platelet count and AST/ALT ratio were found to be the best predictors of advanced fibrosis., Conclusion: In Saudi patients with AIH, we found that the GGT level at presentation may serve as a useful predictor for response to therapy. Platelet count and AST/ALT ratio may be used to predict advanced fibrosis.

Autoimmune hepatitis (AIH) is a chronic inflammatory disease of the liver of unknown cause. Typically, immune suppressive therapy is used initially for treatment, either in the form of steroids or Azathioprime. In a small proportion of patients, steroids resistance or steroid intolerance develops. When patients are unresponsive to steroids, or develop severe significant side effects to their use, alternative treatments must be used. Mycophenolate mofetil (Cellcept) is a potent immune suppressive medication that is used in a wide variety of autoimmune diseases as well as post solid organ transplantation. Data is emerging to suggest that this medication may be used in selected patients with steroid resistance or steroid intolerance. This data is summarized in this review.

Hepatic encephalopathy (HE) is a disturbance of the central nervous system (CNS) function secondary to porto-systemic shunting. It usually occurs in the setting of advanced liver cirrhosis or acute fulminant hepatic failure. An extensive Medline search was undertaken and all relevant papers found were critically examined. Special emphasis was paid to clinical trials and meta-analyses. All guidelines and conference proceedings related to hepatic encephalopathy were also examined. HE presents with a spectrum of neuropsychiatric manifestations that may be quite subtle (minimal HE) or overt, ranging from disturbance of the sleep pattern to deep hepatic coma. Most patients with HE may be diagnosed on clinical grounds only after excluding other causes of neurological disease, but a wide variety of neuropsychological, neurophysiological, and neuroradiological tests may be utilized. The first step in the management of patients with HE should be supportive care. Following that, a significant effort must be exerted to find and correct possible exacerbating factors which may include: renal impairment, infection, constipation, drugs, gastrointestinal bleeding and other factors. Medications used to treat patients with encephalopathy aim to reduce toxin production, increase toxin elimination, and protect the brain from the harmful effects of these toxins. A critical analysis of the evidence concerning most of the available management modalities is presented. Ultimately, all patients with HE must be considered for liver transplantation. It is concluded that early recognition, positive diagnosis, and a multi-target management plan constitutes appropriate management of patients with HE.