Role of vitamin C and rectal indomethacin in preventing and alleviating post-endoscopic retrograde cholangiopancreatography pancreatitis: a clinical study

Background/Aims@#This study aimed to determine whether vitamin C in addition to indomethacin decreases the occurrence and severity of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) occurrence and severity. @*Methods@#This randomized clinical trial included patients undergoing ERCP. The participants were administered either rectal indomethacin (100 mg) plus an injection of vitamin C (500 mg) or rectal indomethacin (100 mg) alone just before ERCP. The primary outcomes were PEP occurrence and severity. The secondary amylase and lipase levels were determined after 24 hours. @*Results@#A total of 344 patients completed the study. Based on intention-to-treat analysis, the PEP rates were 9.9% for indomethacin plus vitamin C plus indomethacin and 15.7% for indomethacin alone. Regarding the per-protocol analysis, the PEP rates were 9.7% and 15.7% in the combination and indomethacin arms, respectively. There was a remarkable difference between the two arms in PEP occurrence and severity on intention-to-treat and per-protocol analyses (p=0.034 and p=0.031, respectively). The post-ERCP lipase and amylase concentrations were lower in the combination arm than in the indomethacin alone arm (p=0.034 and p=0.029, respectively). @*Conclusions@#Vitamin C injection in addition to rectal indomethacin reduced PEP occurrence and severity.

Prevalence of celiac disease in Iranian patients with rheumatologic disorders

Aim: Patients with Systemic Lupus Erythematosus [SLE], Rheumatoid Arthritis [RA], and Fibromyalgia [FM] may have underlying non-diagnosed celiac disease [CD]

Background: The aim of this study was to determine the prevalence of CD in patients with these underlying diseases in Iran

Methods: This cross-sectional study was performed among 300 consecutive patients with SLE, RA, and FM [each group 100 patients] since 2015 to 2017. The blood samples were collected and serum IgA anti-tissue trans-glutaminase [Anti-tTG] level was assessed for all patients. The seropositive patients underwent endoscopy and duodenal/jejunal biopsy according to the Marsh classification

Results: Out of 300 investigated patients with mean age of 41.2 years old, 92% of patients with SLE, RA and fibromyalgia were women. Among 100 patients with SLE, only 1 subject [1%], out of 100 patients with RA 3 subjects [3%], and none of the patients with fibromyalgia were seropositive for CD [with overall prevalence 1.4]. All four patients were female and categorized as Marsh III

Conclusion: The results of the study indicated that patients with lupus have the same prevalence, but subjects with RA had three times higher prevalence rate than normal population for CD. Therefore, CD investigation in these individuals can improve their quality of life

rare presentation of simple renal cyst: gastrointestinal obstruction

Simple renal cysts are one of the most common lesions in elderly. These cysts are usually asymptomatic but when the size of these cysts increase, we would see symptoms such as hypertension, hematuria, flank pain or urinary obstruction. In this study, we explore a case of small bowel obstruction that presented with nausea, repeated vomiting that causes hematemesis, and a submucosal obstructive lesion that was seen in Esophagogastroduodenoscopy [EGD]. After endoscopic ultrasound [EUS] evaluation, we detected a large simple renal cyst and approved our diagnosis with CT scan. We planned a medical treatment for this patient that consist consuming small size meals, 5 to 6 times a day, and high calorie liquids in small volumes. We conclude that simple renal cyst can be one of the cause of extrinsic intestinal obstruction and EUS is affective for differentiation of intrinsic submucosal lesion from extrinsic compression

[Refractory celiac disease; diagnosis, treatment and clinical manifestations]

Celiac disease as an autoimmune disease is predisposes in genetically susceptible subjects due to the consumption of wheat and other grains containing gluten and as a result of immunological responses, villous atrophy, mucosal hyperplasia, and lymphocytic infiltration will be occurred. The only treatment is a lifelong gluten-free diet. Most patients with celiac disease respond to gluten-free diet [GFD]. But in a small percentage of patients, despite full compliance with gluten-free diet, symptoms and mucosal atrophy are remains. When other causes of mucosal atrophy are rejected, the diagnosis of refractory celiac disease [RCD] is suggested. Based on the abnormality in population of intraepithelial lymphocytes [IEL], RCD is divided into two types 1; [RCD I] and type 2 [RCDII]. Prognosis, clinical symptoms and endoscopic findings of RCD I are better and milder than the RCD II. Treatment of RCD I is based on immunosuppressive therapy and RCD II is mostly based on nutritional support and chemotherapeutic agents. In this review the clinical characteristics, diagnostic and treatment approach of RCD will be reviewed

IgG4 associated cholangiopathy: diagnosis, treatment, and outcome

IgG4-associated cholangitis [IAC] is a subgroup of IgG4-related disease, which is more common in elderly men. IAC is frequently coincident with autoimmune pancreatitis [AIP]. However, some IAC cases do not have other organs involvement. The diagnosis of IAC is based on biochemical, radiological, and histological features. Among these, elevated serum levels of IgG4, extra- and intrahepatic biliary strictures [as visualized by cholangiography], lymphoplasmacytic infiltrations in the liver and bile duct tissue, and association with AIP are of key importance. IAC may mimic primary sclerosing cholangitis or cholangiocarcinoma [CC]. It is classically a corticosteroid-responsive condition and corticosteroid is regarded as the initial treatment of choice in this disease. However, relapse following corticosteroid withdrawal is a frequent event

Economic burden made celiac disease an expensive and challenging condition for Iranian patients

Aim: The aim of this study was to estimate the economic burden of celiac disease [CD] in Iran

Background: The assessment of burden of CD has become an important primary or secondary outcome measure in clinical and epidemiologic studies

Methods: Information regarding medical costs and gluten free diet [GFD] costs were gathered using questionnaire and checklists offered to the selected patients with CD. The data included the direct medical cost [including Doctor Visit, hospitalization, clinical test examinations, endoscopies, etc.], GFD cost and loss productivity cost [as the indirect cost] for CD patient were estimated. The factors used for cost estimation included frequency of health resource utilization and gluten free diet basket. Purchasing Power Parity Dollar [PPP dollars] was used in order to make inter-country comparisons

Results: Total of 213 celiac patients entered to this study. The mean [standard deviation] of total cost per patient per year was 3377 [1853] PPP dollars. This total cost including direct medical cost, GFD costs and loss productivity cost per patients per year. Also the mean and standard deviation of medical cost and GFD cost were 195 [128] PPP dollars and 932 [734] PPP dollars respectively. The total costs of CD were significantly higher for male. Also GFD cost and total cost were higher for unmarried patients

Conclusion: In conclusion, our estimation of CD economic burden is indicating that CD patients face substantial expense that might not be affordable for a good number of these patients. The estimated economic burden may put these patients at high risk for dietary neglect resulting in increasing the risk of long term complications

Pathological and clinical correlation between celiac disease and pathological and clinical correlation between celiac disease andpathological and clinical correlation between celiac disease and helicobacter pylori infection; a review of controversial rep

There are overwhelming reports and descriptions about celiac associated disorders. Although there is a clear genetic association between celiac disease [CD] and some gastrointestinal disorders, there are controversial reports claiming an association between CD and Helicobacter pylori [H. pylori] infection. Different studies indicated the possible association between lymphocytic gastritis and both CD and H. pylori infection, although this evidence is not consistently accepted. Also it was shown that an increase in intraepithelial lymphocytes count is associated with both H. pylori infection and celiac disease. Therefore the following questions may raise: how far is this infection actually related to CD?, which are the underlying patho-mechanisms for these associations? what are the clinical implications? what is the management? and what would be the role of gluten free diet in treating these conditions? PubMed [PubMed Central], Ovid, ISI of web knowledge, and Google scholar were searched for full text articles published between 1985 and 2015. The associated keywords were used, and papers described particularly the impact of pathological and clinical correlation between CD and H. pylori infection were identified. In this review we tried to answer the above questions and discussed some of the recent developments in the pathological and clinical aspects of CD and H. pylori infection

Cronkhite-Canada syndrome; a case report and review of the literature

Cronkhite- Canada syndrome [CCS] considered as a rare and non-hereditary disorder. Gastrointestinal polyposis and diarrhea along with some extra signs and symptoms such as hypoproteinemia, and epidermal manifestations are recognized in this syndrome. The pathophysiology of this syndrome is not completely understood and it seems that inflammatory processes may be involved. We present a 50 year-old man with hamartomatous polyps throughout the colon and long-lasting diarrhea not responding to typical therapies during three years

An unusual cause of constipation in a patient without any underlying disorders

Constipation is the most common digestive complaint in the general population. It is associated with considerable adverse effect on quality of life and substantial economic costs and often has no underlying pathology. Non-Celiac Gluten Sensitivity [NCGS] has been described as a cause of constipation in a few studies. We present a 62-year-old male with long standing constipation without any underlying cause during extensive surveys and not responding to any conservative treatment but significant response with gluten free diet [GFD]