Mesalazine has no effect on mucosal immune biomarkers in patients with diarrhea-dominant irritable bowel syndrome referred to Shariati Hospital: a randomized double-blind, placebo-controlled trial

Intestinal mast cells may cause gastrointestinal symptoms in patients with diarrhea-dominant irritable bowel syndrome [IBS]. The objective of this study was to determine the effect of mesalazine on the number of lamina propria mast cells and clinical manifestations of patients with diarrhea-dominant IBS referred to Shariati Hospital affiliated to Tehran University of Medical Sciences

Methods: This was a randomized placebo-controlled double-blind trial conducted on 49 patients with diarrhea-dominant IBS. The patients were randomly assigned to one of the experiment or control groups. The patients in experiment group took 2400 mg mesalazine daily in three divided doses for 8 weeks and the patient in control group took placebo on the same basis. Our first targeted outcome was an assigned downturn of mast cells number to the safe colonic baseline and the next one was a marked palliation of disease symptoms. Data were analyzed conforming intention-to-treat method. We used MANCOVA test to compare our both assigned outcomes in the two groups. We also compared the data with baseline values in both groups. All statistical tests were performed at the significance level of 0.05

Results: There was no significant difference between Mesalazine and placebo groups regarding the number of mast cells [p value=0.396], abdominal pain [p value=0.054], bloating [p value=0.365], defecation urgency [p value=0.212], and defecation frequency [p value=0.702]

Conclusion: Mesalazine had no significant effect either on the number of mast cells or on the severity of disease symptoms. This finding seems to be inconsistent with the hypothesis indicating immune mechanisms as potential therapeutic targets in IBS. The possible difference in this effect of Mesalazine should be evaluated in further studies among populations varying in race, ethnic, and geographical characteristics

[Esophageal perforation due to swallowing a glass body]

Esophageal perforation is a rare yet very serious condition, which usually needs surgical repair. In spite of its rarity, esophageal perforation could become extremely dangerous and even life-threatening. Therefore it needs immediate surgical intervention. The first symptom to appear is pain. Perforation in the middle and lower third of the esophagus might as well cause difficulty in swallowing, dyspnea, and chest pain. A 61-year-old man presented to the Emergency Room due to sensation of a foreign body and epigastric pain after meal for which he underwent upper endoscopy. The foreign body was seen in the lower third of the esophagus. Considering the bilateral penetration of the sharp foreign body to the esophageal wall, no effort was made to bring the foreign body out. The patient underwent computed tomography [CT] without contrast, which showed right posterolateral mediastinal air leakage and slight pleural effusion in the right hemithorax. As recommended by thoracic surgeon, instead of thoracotomy, the foreign body was brought out in the operating room by endoscopy [under preparation in order to convert the procedure to thoracotomy if needed]. After the procedure, a CT with oral contrast was done, which showed free air and leakage of contrast to the right posterolateral hemithorax as well as an increase in the pleural effusion. Normal saline was immediately injected to both sides of the perforation site by endoscopy in order to prevent further leakage. The patient was observed by both surgery and gastroenterology teams for a week to undergo thoracotomy in case he develops mediastinitis. After a week, he underwent Gastrografin swallow and then Barium swallow. The patient was discharged from the hospital because no evidence of remaining perforation or any microperforations were seen. Esophageal perforation is a surgical emergency usually happening due to diagnostic and pass through esophagous to go to the therapeutic actions. Most swallowed foreign bodies stomach, but sharp objects may cause perforation in esophagus. Foreign bodies mostly get trapped in the physiologic constrictions. Dysphagia and odynophagia are subcutanneous common symptoms of foreign body invasion in to the esophagous. Emphysema is a diagnostic key for the matter of esophageal perforation. Treatment for such condition differs among various patients

Nonadherence to medication in inflammatory bowel disease: rate and reasons

Background: This study is the first study to evaluate the nonadherence rate and reasons of same patient with inflammatory bowel disease [IBD] in Iran

Method: During 9 months, 500 patients with IBD were enrolled in the study. Patients were interviewed about their nonadherence behaviors. Factor analysis was used to analyze the collected answers

Results: The overall rate of nonadherence was 33.3% [27.6% intentional nonadherence and 5.7% unintentional nonadherence]. 33.6% of the patients had at least one relapse after discontinuing treatment. The most frequent reason for intentional nonadherence was discontinuing the treatment after recovering from symptoms [42.7%]. The most frequent reason for unintentional nonadherence was forgetfulness [5.2%]. 19.8% of the patients did not visit their gastroenterologist on time and they purchased drugs from the drugstore. These patients reported that their clinics were too far and difficult to access. There was no significant relationship between nonadherence and demographic variables

Conclusion: Multiple reasons are suggested as factors of medication nonadherence and they seem to be different among different populations. Determining these possible reasons, could lead to finding suitable strategies to overcome or reduce them

[Review of pathophysiology and diagnosis of irritable bowel syndrome]

Irritable bowel syndrome is one of the most common functional gastrointestinal disorders with the prevalence of 10-20% of the world's population. This syndrome usually manifests as abdominal pain or discomfort associated with altered bowel habits, and it is usually diagnosed based on patient's history and there is no specific diagnostic test for it. However, it should be noted that definitive diagnosis is made after ruling out other organic diseases. The most common clinical manifestations are abdominal pain or discomfort, constipation, diarra or alternating constipation and diarrhea, and abdominal bloating. Various mechanisms have been described for pathogenesis of this disorder, including motor dysfunction, visceral hypersensitivity, mild inflammation, and stress. Genetic factors seem to be involved in inflammation and regional immune responses and subsequently, susceptibility to IBS. But it seems that several factors are involved in the presentation of IBS symptoms. Although most patients do not refer for medical care, the disease imposes a considerable cost on patient and healthcare system and considerably overshadows the subject's quality of life. Having knowledge about the precise pathophysiology and diagnostic criteria are necessary for better identification of patients and choosing a more appropriate treatment approach.

Stool antigen tests for the detection of Helicobacter pylori in children

Reliable non-invasive methods for detection of Helicobacter pylori [H. pylori] infection are required to investigate the incidence, transmission, and clearance of infection in childhood. Detecting bacterial antigens in stool offer an alternative noninvasive diagnostic test. However its accuracy in developing countries is not well established. The aim of this study was to evaluate the performance of stool antigen test for H pylori in Iranian children with recurrent abdominal pain necessitating endoscopy. One hundred three children enrolled in this study. Endoscopy and biopsy was done on all patients providing a criterion standard for validation of the H. pylori stool antigen [HpSA] tests. The presence of H. pylori organisms in stool was determined by an enzyme-linked immunosorbent assay using a commercially available polyclonal antibody. HpSA sensitivity, specificity, and positive and negative likelihood ratios were determined with reference to the results of cultures of gastric biopsy. Of the 103 children tested 41 [39.8%] and 39 [37.8%] were positive for H. pylori according to the results of cultures of gastric biopsy and HpSA, respectively. The sensitivity, specificity, and positive and negative likelihood ratios of HpSA were found to be 85%, 93%, 89.7%, and 90%, respectively. In this pilot study, a low-cost and rapid diagnostic technique, stool antigen test proved to be highly sensitive and specific for detecting H pylori infection in children with recurrent abdominal pain. Our results are comparable to those reported elsewhere in children and demonstrate that the HpSA test can replace endoscopy and biopsy for detecting H. pylori infection

[Doxepin is more effective than nortriptyline and placebo for the treatment of diarrhea-predominant irritable bowel syndrome: a randomized triple-blind placebo-controlled trial]

The current treatment of IBS is often unsatisfactory and frustrating. Several controlled trials have demonstrated benefits of tricyclic antidepressants for irritable bowel syndrome, especially when pain is a prominent symptom but the efficacy of antidepressants in irritable bowel syndrome is controversial. The aim of this study was to compare the effect of doxepin and nortriptyline on diarrhea-predominant irritable bowel syndrome. Seventy-five patients with IBS according to Rome III criteria were treated for two months. The patients were randomly assigned to one of three groups treated with doxepin, nortriptyline or placebo. Subjects were assessed clinically one month and two months after treatment. The symptoms and adverse effects of the drugs were recorded in the questionnaire. The total score was considered as the number of the symptoms for each patient, which ranged between zero and six. Improvements in abdominal pain and bloating in the doxepin group were significantly higher than the nortriptyline or the placebo groups [P=0.001 and P=0.012, respectively]. However, improvement in diarrhea in patients on nortriptyline was significantly higher than the other groups [P=0.018]. The average improvement of symptoms in the patients after two months of treatment in doxepin, nortriptyline and placebo groups, respectively were 2.56, 2 and 0.6 [P<0.05]. Both doxepin and nortriptyline are effective for the treatment of diarrhea-predominant irritable bowel syndrome in a period of two months but doxepin seems to be more efficacious than nortriptyline in this regard. However, larger comparative trials are suggested

Unexplained infertility as primary presentation of celiac disease, a case report and literature review

Celiac sprue [gluten sensitive enteropathy] is an autoimmune disease which is hereditary and its pathology mainly bases on immunologic intolerance to gluten. It has a vast variety of signs and symptoms and its clinical features range from a silent disease to a typical gastrointestinal disorder. In this study we reviewed and summarized some other related issues about this disease and its relation with infertility. Case: The case is a 26 years old lady who had referred to a gynecologist because of infertility for 2 years and later it revealed that she has celiac sprue. Screening for its silent or subtle types especially among suspicious cases such as unexplained infertility seems to be a cost effective action. Meanwhile, in time administration of a gluten-free diet can lead to an almost complete cure

Isolated vitamin B12 deficiency in a patient with Celiac Sprue

Vitamin B12 deficiency due to pernicious anemia has rarely been reported in celiac sprue. We report a rare case with celiac disease and severe vitamin B12 deficiency due to pernicious anemia without any iron or folic acid deficiency who showed a dramatic response to treatment with vitamin B12 injection

Isolated vitamin B12 deficiency due to pernicious anemia in a patient with celiac sprue: a case report

Celiac sprue or Celiac disease is an autoimmune enteropathy often seen in patients are sensitive to gluten. Usually due to impaired absorption of iron and folic acid at the proximal of small intestine, iron deficiency anemia and megaloblastic anemia is common, but vitamin B 12 deficiency is rarely reported. We will describe the case that in addition to have celiac disease, without deficiency of iron and folic acid, has deficient vitamin B 12 due to severe pernicious anemia and improved dramatically to treatment with injection of vitamin B12. 38-years-old male patient with complaints of weakness and malaise and abdominal pain is referred. Initial tests indicated patient have megaloblastic anemia caused by vitamin B12 deficiency. With stomach and deuodenal biopsy and serological antibody titration studies including anti-parietal cell antibody, anti-endomysial antibody and tissue transglutaminase, accompanied with pernicious anemia and celiac disease was proved. After diagnosis, patients treated with intramuscular vitamin B12 and regimen without gluten, after one month significant improvements in clinical symptoms and laboratory found