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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.

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.

Aim: Differentiation of benign biliary strictures (BBS) from malignant biliary strictures (MBS) remains difficult despite improvement in imaging and endoscopic techniques. The aim of this study was to identify the clinical, biochemical and or radiological predictors of malignant biliary strictures., Methods: We retrospectively reviewed all charts of patients who had biliary strictures (BS) on endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous cholangiography (PTC) in case of unsuccessful ERCP from March 1998 to August 2002. Patient characteristics, clinical features, biochemical, radiological and biopsy results were all recorded. Stricture etiology was determined based on cytology, biopsy or clinical follow-up. A receiver operator characteristic (ROC) curve was constructed to determine the optimal laboratory diagnostic criterion threshold in predicting MBS., Results: One hundred twenty six patients with biliary strictures were enrolled, of which 72 were malignant. The mean age for BBS was 53 years compared to 62.4 years for MBS (P=0.0006). Distal bile duct stricture was mainly due to a malignant process 48.6% vs 9% (P=0.001). Alkaline phosphates and AST levels were more significantly elevated in MBS (P=0.0002). ROC curve showed that a bilirubin level of 84 micromol/L or more was the most predictive of MBS with a sensitivity of 98.6%, specificity of 59.3% and a positive likelihood ratio of 2.42 (95% CI=0.649-0.810). Proximal biliary dilatation was more frequently encountered in MBS compared to BBS, 73.8% vs 39.5% (P=0.0001). Majority of BBS (87%) and MBS (78%) were managed endoscopically., Conclusion: A serum bilirubin level of 84 micromol/L or greater is the best predictor of MBS. Older age, proximal biliary dilatation, higher levels of bilirubin, alkaline phosphatase, ALT and AST are all associated with MBS. ERCP is necessary to diagnose and treat benign and malignant biliary strictures.

Objective: To describe microscopic colitis (MC) and a stepwise approach to its diagnosis and management., Quality of Evidence: MEDLINE was searched from January 1996 to August 2002. Controlled trials were sought, but due to their relative rarity, most articles cited are well designed retrospective studies and reviews., Main Message: Microscopic colitis in both its collagenous and lymphocytic forms is a relatively common and important cause of diarrhea in middle-aged and elderly patients. It usually presents as chronic watery diarrhea. Results of endoscopic and radiologic examinations are normal; specific histologic findings are seen on colonic biopsy. Once the diagnosis is confirmed, we suggest a stepwise approach to therapy. First-line therapies include antidiarrheal agents; second-line include bismuth subsalicylates and budesonide; third-line include cholestyramine and 5-aminosalicylic acid agents. When patients fail to respond to these therapies, oral corticosteroids or immune modulatory therapy should be considered. For severe unresponsive cases, colectomy is the last resort., Conclusion: Microscopic colitis is an important cause of chronic diarrhea. Once the diagnosis is confirmed, a stepwise approach to treatment is suggested.