[Duodenal kissing ulcer [sealed anterior perforated duodenal ulcer combined with hemorrhagic posterior ulcer]: report of a case]

Peptic ulcer disease and its complications have long been studied but the coexistence of two major complications in a kissing ulcer is uncommon. We present our experience with this entity and review the related literature. A 27 year old man was suffering from concomitant major complication of duodenal kissing ulcer, huge anterior perforation and uncontrolled posterior bleeding, presenting as hemorrhagic shock to emergency department. The posterior ulcer containing pulsatile bleeding from gastroduodenal artery oversewed and the ruptured anterior ulcer converted to pyloroplasty followed by truncal vagotomy. Presence of anterior perforated duodenal ulcer in a patient of bleeding peptic ulcer is an uncommon presentation that needs a high degree of suspicious for preoperative and intraoperative diagnosis

Occupational lead poisoning in workers of traditional tile factories in Mashhad, northeast of Iran

Occupational lead poisoning is a health problem in Iran. It has not previously been studied in traditional tile makers. To determine the prevalence of lead poisoning and its complications in traditional tile workers in Mashhad, Northwest of Iran, We visited workers in two traditional tile factories and collected data by direct history taking and physical examination. Blood and urine lead concentrations were measured by heated graphite atomization technique. Overall, 108 men with mean +/- SD age of 37 +/- 7.8 years were studied. The mean +/- SD length of daily lead exposure was 9.8 +/- 6 years. The mean +/- SD blood lead concentration was 520.5 +/- 323, 2 M9/L. The main objective clinical findings were the presence of lead line [64.8%], peripheral neuropathy of the upper extremities [37%], depressed deep tendon reflexes in the upper extremities [25.7%], tremor [23.3%], peripheral neuropathy of the lower extremities [17%] and abdominal tenderness [15.1%]. The subjective findings were mainly attributed to the central nervous system and included loss of memory [57%], moodiness [56.1%], agitation [47.7%], drowsiness [36.4%] and headache [29.9%]. There was no statistically significant correlation between the blood lead concentration and glomerular filtration rate. However, there were significant correlations between the blood lead concentration and each of the urine lead concentration [p<0.001], diastolic blood pressure [p=0.04], serum triglyceride level [p=0.043], high density lipoprotein level [p=0.012], and basophilic stippling [p=0.048]. Blood lead level, however, did not have any significant correlation with the presence of lead line. In traditional tile workers, lead toxicity is not uncommon and the toxic effects of lead were found more often on the teeth [bone], central and peripheral nervous system, hematological and lipid profiles than on the renal function

Insulin resistance and related factors in non-alcoholic fatty liver disease [NAFLD]: an analytic cross-sectional study

Non-alcoholic fatty liver disease [NAFLD] is characterized by fatty change of liver without inflammation. The aim of this study was to evaluate presence of clinical and metabolic components in non-diabetic patients with NAFLD and to assess the relationship between insulin resistance and these factors. In this study, a group of 50 sonographically confirmed patients with NAFLD was studied. Following an overnight fasting, blood samples were obtained to measure serum levels of Triglyceride, Cholesterol, Low Density Lipoprotein [LDL-C], High Density Lipoprotein [HDL-C], SGOT and SGPT, haemoglobin A1C, Fasting Blood Sugar [FBS] and peripheral blood insulin level. Based on homeostatic model assessment [HOMA] score, patients were divided into four quartiles. Other variables including BMI, waist and hip circumference were also measured. The mean age was 42 +/- 10.3 years [range, 22-65], 33 cases [66%] were men, and 17 cases [34%] were women. Mean insulin level was higher in females [female=15.3 +/- 6.7, males=12.9 +/- 5.7]. Variables including waist [P=0.38] and LDL-C [P =0.49] were significantly different among defined study groups. The higher the HOMA index, the lower the HDL-C level [P <0.05]. Patients with insulin resistance showed significant higher values of LDL and Waist circumference. Values of HDL were significantly lower in these patients. Body mass index, Weight, Triglyceride, Cholesterol, AST and ALT values showed no relation with insulin resistance

[Effects of using mitomycin-C in treatment of benign esophageal strictures]

Using bouginage or balloon dilatation is the standard treatment for benign esophageal strictures. About two-thirds need repeated dilatations. For preventing recurrent strictures, many medications such as mitomycin-C have been used. Mitomycin-C is a special antibiotic with anti-neoplastic characteristics, which inhibits fibroblast proliferation, reduces collagen production and decreases scar formation. In this study, 12 patients with benign esophageal stricture during Azar 1386 to Bahman 1387 in Imam Khomeini Endoscopy Department were included. Esophageal endoscopy was done and mitomycin-C was applied on the place of stricture using a cotton ball. Then, response to treatment was categorized in three groups of complete response, partial response and non-response to treatment. Average number of using mitomycin-C was 4 +/- 3 times. Mean interval between endoscopies before using mitomycin-C was 3.5 +/- 1 weeks and after using this agent was 8.5 +/- 4.3 weeks. There were 4 cases of complete response, 5 cases of partial response and 3 patients of non-response. Conservative treatments in management of benign esophageal strictures are preferred to more invasive treatments. However, it seems using a topical solution of mitomycin-C carries better responses and reduces the rate of recurrent dilatations

Giardia lamblia and Helicobater pylori coinfection

Giardia lamblia and Helicobacter pylori are two flagellate microorganisms that grow in duodenum and stomach. The aim of this study was to evaluate the prevalence of them in patients with dyspepsia and other GI disorders. In this cross-sectional study, co-infection of above-mentioned agents was investigated in a group of 130 patients [median age of 40 yr [range=11-79] including 76 males [58.8%]] with dyspepsia using three methods of duodenal aspiration sample, duodenal biopsy samples and evaluation of stool samples. From 105 patients [59 males, 46 females, median age 40 years, range 11-79] entering this study from 3 hospitals, 4 patients [3.8%] had G. lamblia and 61 patients [58%] had H. pylori. All 4 patients infected by Giardia had also H. pylori infection. Tenesmus [3 out of 4 patients] was the most common symptom in patients with H. pylori infection [48 out of 61 patients] was reflux. Other symptoms in patients infected with both organisms [4 patients] included diarrhea [2 cases], weight loss [2 cases], and loss of appetite [1 case] but no report of vomiting. In patients co-infected with Giardia, H.pylori differentiation by physical examination is not possible. So in those patients with positive Rapid Urease Test [RUT], stool examination for Giardia detection is recommended. In addition, metronidazole [broad spectrum, anti-protozoal drug] can be useful in H. pylori infection

Mast cell stabilizers as a potential treatment for Irritable bowel syndrome: a randomized placebo-controlled clinical trial

Mast cells are believed to play a role in irritable bowel syndrome pathogenesis and symptom genesis due to their close neighborhood to gastrointestinal innervations. This study was designed to evaluate the efficacy of orally administered cromolyn for reduction of symptoms in patients with irritable bowel syndrome [IBS]. A randomized placebo-controlled double-blinded 6x6 weeks cross-over study was performed in a private gastrointestinal clinic. 10 patients were allocated to group A and 6 patients to group B. Patients in group A received 150 mg cromolyn divided in three equal doses for the first 6 weeks and placebo for the next 6 weeks but patients in group B received placebo for the first 6 weeks and cromolyn in the next 6 weeks. Weekly evaluation was performed and visual analogue scale was used to determine severity of symptoms. Sixteen patients completed the study. Mean age of the patients was 40.3 +/- 10.9 years old [range: 24-57]. Eight patients had D-IBS [Diarrhea dominant] and other 8 had CIBS [Constipation dominant]. Both cromolyn sodium and the placebo decreased the severity of bloating [Freidman test, p 0.001 and 0.006 respectively]. The severity of the main symptom [diarrhea or constipation] did not decrease in patients of group A and B who were treated with different sequences of the drug or placebo. The severity of pain decreased drastically after 6th week of treatment with cromolyn. Freidman test showed a significant difference between the pain levels of the former defined treatment spots [p 0.01, and 0.02 for patients in group A and B, respectively]. No adverse drug reactions were observed during the study. In conclusion, long term administration of cromolyn seems to be partially effective for treatment of abdominal pain in patients with IBS while main symptoms [diarrhea or constipation] might not decrease during this treatment

Diagnosis and treatment of constipation: a review

Constipation is a common medical problem that imposes multiple clinical referrals in addition to familial and social impacts. The condition is functional in most cases, despite the presence of several etiologies, especially in severe cases and patients unresponsiveness to treatment. Assessment of secondary causes are important. A comprehensive and economic diagnostic and treatment approach for the large number of cases suffering from this medical problem is essential. In medical history and physical examination, the patient's aim regarding the word "constipation" should be considered, and symptoms and signs of secondary causes [such as weight loss, gastrointestinal bleeding, anemia, and ...] should be evaluated. In cases without these alarming clues, treatment with fibers, diet, liquids, physical activity and discontinuation of medications resulting in constipation can be recommended. Re-evaluation of patients in order to find out other defecation problems, slow transit of colon, and secondary causes like malignant or metabolic etiologies should be considered. Defecation problems resisting medical treatment, are always responding to biofeedback treatment. Psychological support and consultation are also helpful in treatment. Long term consumption of medications affecting constipation should be considered with due regard to their side effects. Surgical operations might be performed in unresponsive patients. It should be mentioned that success of surgical methods are greatly dependent on concise selection of patients; lowest success are detected in cases with background psychological problems. Researches on new treatment options for constipation are continually conducted

[Gastric lipoma: a case report]

Lipomas are rare gastric tumors that comprise less than 1% of gastric tumors. These tumors are usually without clinical manifestations, but sometimes they may present with severe symptoms like bleeding, intussusception, or abdominal pain. In endoscopic assessment, they manifest with subm ucosal masses with intact epithelium. Endosonography and CT scan can help in diagnosis. Surgical resection of the mass and pathologic examination confirm the diagnosis. This case report, presents a patient that referred with upper gastrointestinal bleeding [melena]. Endoscopic examination revealed a submucosal mass with intact epithelium. Endosonography detected a mass with increased echogenicity that was suggestive of lipoma. The patient underwent a surgical operation for resection of the mass and the diagnosis of lipoma was confirmed by pathology. Although gastric lipomas are rare, they should be considered in evaluation and differential diagnosis of gastric bleeding due to submucosal masses. Endosonography can differentiate lipomas precisely before surgery among submucosal lesions

[Congenital factor VII deficiency in a family in Mashhad: a case report]

Inherited factor VII deficiency is a rare autosomal recessive coagulation defect. The most prevalent bleeding symptoms in these patients are mucus membrane type bleeding, such as epistaxes. This study was done to report disease in a family due to its rarity and widely variant differential diagnosis. A 4.5 years old son was admitted with recurrent epistaxes. This symptom had been observed in his younger brother, too. Parents and his sisters were asymptomatic. Parents were causins. Laboratory finding in two symptomatic brothers consisted of increased PT [prothrombin time] with patient PT to control ratio greater than 2, and F VII coagulation level less than%1. In parents and one of their daughters, mild increase in PT and some decrease in F VII coagulation level in the range of% 50-60 was observed. The most prevalent symptoms in congenital FVII deficiency are mucus membrane bleeding, including epistaxes and menorrhgia. Patients with level of factor VII less than 1% of normal, usually present with severe clinical signs. The level of Factor VII in carriers [heterozygote] is 25-75% of normal, but in hemozygote state it is less than 25%. In our cases with hemozygote state, the only clinical sign was recurrent epistaxes but carriers had no sign. In hemozygote patients the level of factor VII was less than 1% and in heterozygote ones between%50-60

[ correlation between helicobacter pylori infection and serum ferritin concentration and iron deficiency anemia]

Iron deficiency is the most common cause of anemia worldwide, however a significant number of these patients remain undiagnosed. Based on the high frequency of iron deficiency anemia and H. pylori infection in Iran, This study was done to evaluate their correlation. This descriptive study was done in Imam Reza Hospital in the year 2005. 184 patients mostly with GI system complaints were referred for determination of serum anti H.pylori IgG and IgA levels. In addition, we performed complete cell blood count and serum ferritin concentration tests for all the patients. Individual, cell blood count and serum ferritin concentration data were gathered in a questionnaire. Statistical analysis was performed by SPSS software and descriptive statistics. Our results showed that in 77.8% of our patients at least one of serum anti H. pylori IgG or IgA antibodies were positive. The rate of positive serology was increased in higher age groups. Patients' gender did not influence the results. Serum ferritin level did not show any correlation with H. pylori infection and the frequency of iron deficiency anemia was not higher in infected individuals. Although many studies have shown positive correlation between H. pylori infection and iron deficiency anemia, few studies have not confirmed these findings. Our study does not support this correlation, as well. Due to high frequency of both iron deficiency anemia and H. pylori infection in Iran, further large scale studies are recommended

[Neuroborreliosis during relapsing fever and a case report]

Relapsing fever is a spirochetal disease that is caused by different Borrelia species. Relapsing fever is well recognized as an infection of the blood, characterized with episodes of fever, rigor and spirochetemia; but little is known about its predilection for nervous system. This report is supposed to present a patient with neuroborreliosis during relapsing fever. The presented patient in this paper is a 22 year old woman from Afghanistan with clinical features of meningitis and recurrent episodes of fever with rigor. In diagnostic evaluation, the patient had a CSF profile with aseptic meningitis pattern, and in third time peripheral blood smear spirochet was reported. With diagnosis of meningitis during relapsing fever, she was treated by intravenous ceftriaxone. With administration of first dose of ceftriaxone, Jarisch - Herxheimer reaction occurred. Patient was treated for 14 days by intravenous ceftriaxone. At the end of treatment, the patient was symptom free and had a normal CSF profile. Therefore patient was discharged. In the patients with aseptic meningitis in endemic regions, besides common agents, relapsing fever should also be considered

[Evaluation of blood and blood products consumption in Emam Reza hospital of Mashhad]

Blood bank Must try to provide high quality blood products with minimal wasting. This goal is achieved by optimal blood utilization management. For this purpose have to be aware of this process in the field. In a one year period during the year 1382, the amount of requested blood units and its components [FFP, cryoprecipitate, platelet] their usage, outdating and cross match to transfusion ratio [C:T] evaluated in different departments of Emam Reza a general hospital in Mashhad. We also estimated average daily, weakly and yearly usage of each ABO groups and Rh type. From 1243 Blood units, 2950 [23.8%] units were been expired in many of hospital departments especially in angiography, kideney transplant, heart, and obstetric/Gynecology; C:T ratio was greater than 2. Daily usage of blood in this hospital was 26 units. During this period, 7035 platelet units were used. The most usages were seen in hematology and internal emergency department. In addition, 11213 FFP units have been used. The most usage of FFP was seen in burn department. In comparison to international standards, Blood wasting rate was higher C:T ratio greater than 2 usually indicates excessive cross match requests. In order to decrease this ratio, usage from a local guideline is advised. Hospital transfusion committees have to supervised blood and blood components requests and consumptions