Antoine Abou Rached

Objective: The objective of the study was to review available data on IBD in Lebanon based on histopathological reports and endoscopic data to identify the number of newly diagnosed cases per year, age, gender, and disease phenotype, and subsequently update the incidence and prevalence of the disease. Methods: A review of all histopathological reports of newly diagnosed IBD patients over a 20-year period was conducted, along with a review of available clinical and endoscopic information at the National Institute of Pathology. The clinical data analysed included the type of IBD, age, gender, number of cases diagnosed per year, location of each IBD type and disease progression over time. The Montreal classification for age and phenotype was applied to both diseases. Results: Over a 20-year period (from January 2000 to December 2020), 2,869 IBD patients (1,365 with Crohn’s disease (CD) and 1,504 with ulcerative colitis (UC) were included. Our sample represents 20% of the Lebanese population with IBD. No cases of unclassified IBD were identified since all patients were followed up throughout the years. The male-to-female ratio was 1.15 for UC patients and 1.3 for CD patients. The average age was 41 years for UC and 36.4 years for CD. Ileal involvement and left-sided colonic involvement were the most frequently noted in CD and UC, respectively. A progressive increase in diagnosed cases of CD and UC was observed over this 20-year period. The annual incidence rose from 4.9 to 11 per 100,000, with a cumulative incidence of 6.53 per 100,000 and a prevalence of 130.56 per 100,000. The highest incidence occurred between ages 21–30. Incidence trends were independently predicted by age group and calendar period, with markedly higher rates among individuals aged 20–39 and 40–59 years with a significant increase in the 2015–2020 period, whereas sex and disease type showed no significant associations. Conclusion: Epidemiological data demonstrated a progressive increase in the incidence of IBD over this 20-year period, with a slight male predominance. Ileal involvement is predominant in CD, whereas involvement extending beyond the splenic flexure is present in more than half of UC cases.

Rationale: Gastrocolic fistulae represent abnormal connections between the stomach and large intestine, often leading to chronic diarrhea and malnutrition. They can arise postoperatively, particularly after complex surgeries such as the Billroth II procedure. Patient concerns: This case report describes the case of a 71-year-old male, with a history of hypertension and gastrointestinal surgery, who experienced significant weight loss and postprandial diarrhea. Initial investigations, including stool cultures and multiple imaging studies, failed to reveal the fistula. Diagnoses: A definitive diagnosis of gastrojejunocolic fistulae was made during the third gastroscopy, when the endoscope passed from the stomach into the colon. Interventions: Surgical intervention involved adhesiolysis and resection of the fistula, followed by reconstruction of gastrointestinal continuity. Outcomes: Postoperative care included nutritional support, and the patient showed a significant improvement at follow-up. Lessons: This case highlights the diagnostic challenges associated with gastrojejunocolic fistulae and emphasizes the need for a high index of suspicion in patients with atypical gastrointestinal symptoms after complex surgery. This illustrates that timely surgical intervention can lead to positive outcomes, and underscores the importance of ongoing research and education regarding the management of such complications. Further studies are needed to understand the long-term effects of gastrojejunocolic fistulae and optimize management strategies.

The pandemic of coronavirus disease 2019 (COVID-19) has caused over four million deaths, depleting resources and healthcare workers; therefore, in an attempt to stratify patients, the relationship between liver enzymes and clinical outcome was studied. This study aimed to assess the pattern and impact of liver enzymes on the clinical outcome of hospitalized patients with COVID-19 in Lebanon and look for possible confounding factors. This was a single-centered retrospective cohort study conducted between December 2020 and March 2021 on 230 patients diagnosed with COVID-19. Liver function tests (LFTs) and other laboratory values on admission and peak hospitalization were analyzed using SPSS. The prevalence of abnormal liver tests among the sample population with severe COVID-19 infection were as follows: aspartate aminotransferase (AST), 77%; alanine aminotransferase (ALT), 49%; alkaline phosphatase (ALP), 12%; and gamma-glutamyl transferase (GGT), 37%. A severe COVID-19 infection was more likely present in patients with abnormal levels of AST (p = 0.015), ALP (p = 0.03), and GGT (p = 0.022). ANOVA test revealed no significant relationship between AST levels at peak hospitalization and the treatments received by the patient. Abnormal liver function tests of patients at admission may be an indicator of more severe disease. In the context of scarce resources created by the pandemic, it becomes essential to establish a reliable predictor for a severe outcome of COVID-19 infection and manage accordingly.

The worldwide epidemiology of Inflammatory Bowel Disease (IBD) is changing. Increasing Crohn’s disease (CD) and Ulcerative Colitis (UC) incidence and prevalence have been recorded. In Lebanon, the current status of IBD is not well known. The aim is to report patients’ characteristics newly diagnosed with IBD in Lebanon based on Montreal classification and to report the prevalence and the incidence of IBD in the Lebanese population during a period of 20 years. This is a retrospective study conducted in collaboration with the National Institute of Pathology, from January 2001 till December 2020 were reviewed. Patients were characterized based on: sex, age at diagnosis, year of diagnosis, location and extension of the disease. A total of 3101 new IBD cases were identified (1504 UC, 1597 CD), mean age for UC and CD was 41.05 years and 36.5 years, respectively. sex ratio (M/F) of 1.15 and 1.29 in UC and CD, respectively. In UC, the 3 age groups distribution, ≤ 16 years, 17–40 years and > 40 years were 5.72%, 47.83% and 40.45%, respectively. Regarding the location distribution, E3 was the most prevalent (55.6%), followed by E1 (24.6%) and E2 (19.8%); with no difference between male and female. Similar pattern of location distribution was noted in the 3 age groups. There was no difference in age of diagnosis but a significant increase of E3 from 40% (2001–2010) to 60% (2011–2020) was noted. In CD, 5.54%, 58.93% and 35.53% of patients were aged ≤ 16 years, 17–40 years and > 40 years, respectively. L1, L2, L3 and L4 represented 57.8%, 16.72%, 23.42% and 1.88% of the location distribution, respectively; without difference between male and female. L1 is significantly higher in the young age groups (≤ 16 years: 68.75% and 17–40 years: 67.72%) compared to the older age group (> 40 years: 39.06%) whereas L2 and L3 were higher in the older age group. When divided into two 10-year periods, there was a significant increase of L1 (63%) in the last 10 years (2010–2020) compared to the 10 years before (40%) and an increase of the disease incidence in the age group 17–40 years. Based on all these data, we calculated the incidence of UC and CD and their progression during this period of 20 years. We noted a progressive increase of the incidence of IBD, especially for CD in the last 3 years. The cumulative incidence of UC and CD were 4.686 and 4.582, respectively. The prevalence of UC and CD were 69.9 par 100000 and 68.35 per 100000, respectively. The mean age of IBD in Lebanon is higher than that described in Europe and North America. Pancolitis in UC and ileal involvement in CD remain the most common forms found. There was an increase of the incidence of IBD during the last 20 years and especially of CD during the last 3 years

Background: People who inject drugs (PWIDs) are prone to a number of blood-borne viral infections. Hepatitis B virus (HBV) and hepatitis C virus (HCV) constitute an important public health concern in this high risk group. Aims: We aimed to determine the prevalence of HBV and HCV antibody among PWIDs in Lebanon. Methods: We conducted a prospective cross-sectional study between June 2015 and June 2016 on PWIDs recruited through Lebanese nongovernmental organizations in collaboration with the Lebanese Ministry of Public Health. The participants were tested for HBs antigen and HCV antibody using rapid test kits. The prevalence of each virus was then calculated. The correlation between both infections and other possible risk factors was also analysed. Results: A total of 250 people were included in our study, of whom 98% were males. Mean age was 31.9 (standard deviation 8.7) years. The prevalence of HBsAg and anti-HCV among PWIDs was 1.2% and 15.6%, respectively. Older age, longer duration of drug use and lack of awareness were significantly correlated with a higher rate of HCV infection (P < 0.01). The high rate of needle sharing among our PWIDs significantly affected the prevalence of anti-HCVAb. Conclusion: PWIDs remain the subpopulation most affected with chronic HCV in Lebanon.

Giant inflammatory polyps (GIPs) are a rare complication of IBD resulting from chronic regenerative and healing processes leading to a polypoid formation on inflamed mucosa. We reported a case of GIP in a patient with long standing left-sided ulcerative colitis (UC); a well circumscribed sessile GIP was found during a colonoscopy for colorectal cancer screening on a normal colonic mucosa in the cecum. After a severe flare of the left-sided colitis and due to partial response to steroids patient was treated with adalimumab; new colonoscopy after 6 months shows complete disappearance of the GIP previously described. It is the first case report of GIP in normal macroscopic mucosa with complete disappearance after biologic treatment.

Purpose: To analyze the hepatitis C virus (HCV) burden in Lebanon and the value of comprehensive screening and treatment for different age groups and fibrosis stages. Methods: We used a multicohort, health-state-transition model to project the number of HCV genotype 1 and 4 patients achieving a sustained virologic response 12 weeks after treatment or progressing to compensated cirrhosis (CC), decompensated cirrhosis (DCC), hepatocellular carcinoma (HCC), or liver-related death (LrD) from 2016 to 2036. In the low/medium/high screening scenarios, the proportion of patients screened for HCV was projected to increase to 60%/85%/99%, respectively, by 2036. We analyzed four treatment strategies: 1) no treatment, 2) all-oral direct-acting antivirals (DAAs) given to F3–F4 (CC) patients only, 3) all-oral DAAs to F2–F3–F4 (CC) patients, and 4) all-oral DAAs to all fibrosis patients. Results: Low, medium, and high HCV screening scenarios projected that 3,838, 5,665, and 7,669 individuals will be diagnosed with HCV infection, respectively, from 2016 to 2036, or 40% of those aged 18–39 years, and 60% of those aged 40–80 years. With no treatment, the projected number of patients reaching CC, DCC, HCC, or LrD in 2036 was 899, 147, 131, and 147, respectively, for the 18–39 years age group. For the 40–80 years age group, these projections were substantially greater: 2,828 CC, 736 DCC, 668 HCC, and 958 LrD. The overall economic burden without treatment reached 150 million EUR. However, introducing DAAs for F0–F4 patients was projected to increase the proportion of remaining life-years spent in sustained virologic response 12 weeks after treatment by 43% and 62% compared to DAAs given at F2–F4 or F3–F4 only, respectively. Conclusion: An enhanced screening policy combined with broader access to DAAs can diminish the future clinical and economic burden of HCV in the Lebanese population and, for the middle-aged and elderly, provide the greatest health benefit with net cost savings.

Objectives: The treatment of hepatitis C has dramatically improved since the introduction of new direct-acting antivirals (DAAs). The aim of this study was to assess the efficacy and safety of all oral DAAs, with or without ribavirin, in the treatment of naive and treatment experienced hepatitis C virus (HCV) Lebanese patients. Methods: This study reviewed all cases approved for hepatitis C treatment with DAAs, according to Lebanese guidelines for treatment of HCV at the Ministry of Public Health from October 2015 to December 2016. Available data on age, gender, genotype (GT) and subtype, fibrosis stage, previous treatment (if present), new DAAs treatment, and sustained virological response at week 12 (SVR12) were collected. Results: During a period of 15 months, a total of 186 patients were treated with DAAs. In total, 57% were male. The mean age of the patients was 54.3 years. Genotype 1 was the most prevalent (45%), followed by genotype four (34%) and genotype three (12%). More than 72% of patients had advanced fibrosis (F3 - F4) before starting DAAs and 42% of patients were treatment experienced. Regarding the different DAAs protocols used, SVR12 was achieved in 93% of cases, while 4% did not achieve SVR. Furthermore, 3% of cases were either lost to follow up or had major adverse events. Sustained virological response at week 12 was 93%, 96%, and 94% in GT1, GT3, and GT4, respectively. In cirrhotic patients, SVR12 was 90%. There was no difference in SVR12 between treatment naive and treatment-experienced patients. Hepatocellular carcinoma developed in five patients during the period of the study. Conclusions: This is the first real world Lebanese data concerning hepatitis C treatment with DAAs. It showed a satisfactory response rate irrespective of previous treatments or the stage of fibrosis. Keywords: Hepatitis C; Fibrosis; Genotype; Antivirals

We report two cases of giant inflammatory polyposis (GIP) with totally different presentation and evolution. The first patient had two giant pseudopolyps after one year of the diagnosis of UC. The second patient had one obstructive giant pseudopolyp secondary to CD at the level of the transverse colon, being totally asymptomatic years before the presentation. GIP is a rare complication of inflammatory bowel disease (IBD). It consists of numerous filiform polyps that look like a “mass of worms” or a “fungating” mass. Surgical resection is inevitable when GIP presents with obstructive symptoms.