Improving quality of care in patients with liver cirrhosis

Liver cirrhosis is a major chronic disease in the field of digestive diseases. It causes more than one million deaths per year. Despite established evidence based guidelines, the adherence to standard of care or quality indicators are variable. Complete adherence to the recommendations of guidelines is less than 50%. To improve the quality of care in patients with cirrhosis, we need a more holistic view. Because of high rate of death due to cardiovascular disease and; neoplasms, the care of comorbid conditions and risk factors such as smoking, hypertension, high blood sugar or cholesterol, would be important in addition to the management of primary liver disease. Despite a holistic multidisciplinary approach for this goal, the management of such patients should be patient centered and individualized. The diagnosis of underlying etiology and its appropriate treatment is the most important step. Definition and customizing the quality indicators for quality measure in patients are needed. Because most suggested quality indicators are designed for measuring the quality of care in decompensated liver cirrhosis, we need special quality indicators for compensated and milder forms of chronic liver disease as well. Training the patients for participation in their own management, design of special clinics with dedicated health professionals in a form of chronic disease model, is suggested for improvement of quality of care in this group of patients. Special day care centers by a dedicated gastroenterologist and a trained nurse may be a practical model for better management of such patients

[Using data mining for identify patients at high risk to hepatocellular carcinoma in the cirrhosis liver: preliminary report]

Data mining has an interdisciplinary field including various scientific disciplines such as: database systems, statistics, machine learning, artificial intelligence and the others. In the field of medical, data mining algorithms can help physicians to diagnose diseases and chose the best type of treatment. Hepatocellular carcinoma has the most common type of liver cancer. Given the poor prognosis, Hepatocellular carcinoma [HCC] has the fourth leading cause of cancer-related deaths. In this article we aimed to build a decision support system which helps physicians for identify patients at risk to liver cancer. We analyzed 258 patients with cirrhosis liver. Patients have followed up for four years. We have used decision tree as a data mining tool, for identify patient at high risk to Hepatocellular carcinoma. Decision tree determined the importance of attributes such as creatinine, INR and BMI which could be useful for prediction of cancer. From decision tree model, cirrhosis disease classification rules were extracted and used to improve the prediction of HCC. Decision tree could identify patients at risk to liver cancer with the accuracy of 88% for patients with Sustained virological response [SVR] and the accuracy of 92% for patients with non SVR found. According to decision tree results, attributes such as etiology, age, BMI, Platelet, Total Bilirubin, INR, Creatinine, Alfafetoproteina [AFP], and Serum Albumin can predict HCC in patient with cirrhosis. It is suggest that results examine with a greater number of patient

Mean polyp per patient is an accurate and readily obtainable surrogate for adenoma detection rate: results from an opportunistic screening colonoscopy program

The incidence of colorectal cancer is rising in several developing countries. In the absence of integrated endoscopy and pathology databases, adenoma detection rate [ADR], as a validated quality indicator of screening colonoscopy, is generally difficult to obtain in practice. We aimed to measure the correlation of polyp-related indicators with ADR in order to identify the most accurate surrogate [s] of ADR in routine practice. We retrospectively reviewed the endoscopic and histopathological findings of patients who underwent colonoscopy at a tertiary gastrointestinal clinic. The overall ADR and advanced-ADR were calculated using patient-level data. The Pearson's correlation coefficient [r] was applied to measure the strength of the correlation between the quality metrics obtained by endoscopists. A total of 713 asymptomatic adults aged 50 and older who underwent their first-time screening colonoscopy were included in this study. The ADR and advanced-ADR were 33.00% [95% CI: 29.52-36.54] and 13.18% [95% CI: 10.79-15.90], respectively. We observed good correlations between polyp detection rate [PDR] and ADR [r=0.93], and mean number of polyp per patient [MPP] and ADR [r=0.88] throughout the colon. There was a positive, yet insignificant correlation between advanced ADRs and non-advanced ADRs [r=0.42,p=0.35]. MPP is strongly correlated with ADR, and can be considered as a reliable and readily obtainable proxy for ADR in opportunistic screening colonoscopy programs

Characteristics of colorectal polyps and cancer; a retrospective review of colonoscopy data in Iran

Early diagnosis and endoscopic resection of adenomatous polyps is the main approach for screening and prevention of colorectal cancer [CRC]. We aimed to assess polyp detection rate [PDR] and to characterize demographic, clinical, and pathological features of colorectal polyps in an Iranian population. We retrospectively analyzed the data from 5427 colonoscopies performed during 2007-2012 at Masoud Clinic, the main endoscopy center associated with Sasan Alborz Biomedical Research Center, in Tehran, Iran. Our sample included 2928 [54%] women and 2499 [46%] men, with the mean age of 48.3 years [SD=16.1]. The most common reasons for colonoscopy included screening in 25.0%, and gastrointestinal bleeding in 15.2%. Cecal intubation was successful in 86% of patients. The quality of bowel preparation was fair to excellent in 78.1% [n=4235] of colonoscopies. Overall PDR was 42.0% [95% CI: 40.6-43.3]. The PDR in men [51.1%, 95% CI: 49.1-53.1] was significantly higher than women [34.2%, 95% CI: 32.4-35.9, p<0.001]. Polyps were more frequently observed in patients after the 6th decade of life [F=3.2; p=0.004]. CRC was detected in 2.9% [73/2499] of men and 1.9% [57/2928] of women [p=0.02]. The mean age for patients with cancer was significantly higher than that for individuals with polyps, 60.9 [SD=13.4] year vs. 56.9 [SD=13.7] year, respectively [p=0.001]. Almost 82.8% of the lesions were precancerous with tubular type predominance [62.3%] followed by tubulo-villous [10.3%], villous [6.6%], and serrated [3.6%]. Hyperplastic/inflammatory polyps comprised 17.2% of lesions. Distal colon was more prone to develop polyps and cancer than proximal colon in our series. These findings provide a great infrastructure for next preventive programs and have implications for colorectal cancer screening at population-level

young woman with multiple liver cysts

A 29-year-old housewife presented with abdominal pain and abnormal results on liver function tests [table 1]. The patient was from a rural area [Garmsar, Iran] and there was no family history of a similar disease. Her family owned various animals most notably jackals, dogs, and cats. The animals were not receiving regular veterinary check-ups, preventive care, or even vaccinations. The patient underwent a liver sonography and multiple echogenic liver cysts were reported. Consequently, an abdominal CT scan was done which showed multiple cysts in her liver [figure 1]. The radiological findings suggested multiple cystic lesions of the liver and patient's history raised the suspicion of hydatid disease. To confirm this diagnosis, a serological study of IgG ELISA for echinococcal antigens was done which yielded positive results. A surgical consultation was done; however, the medical treatment was selected by the patient. Therefore, treatment with albendazole was started

[Discovering hidden cluster structures in patients with cirrhosis based on laboratory data]

Liver cirrhosis was one of the most important liver diseases. Other chronic liver diseases could be lead to liver cirrhosis. Liver cirrhosis could be lead one kind of liver cancers named hepatocellular carcinoma. Cirrhosis in the early stages just by laboratory and imaging testes could be diagnosed. In this study cirrhotic patients were classified based on laboratory symptoms. For this purpose data mining approach has been used in this research. Data mining was an interdisciplinary science that discovers the hidden knowledge in the data. We used K-Means algorithm to categorize the statues of cirrhotic patients. In order to determine the quality of clustering results and to find the best number of clusters, we have used silhouette indices. Our data consists of 410 records which have been collected from Dr. Shariati hospital. The number of features in this study are 0.1 items and sampling were divided into two main groups. At first, we have done clustering based on 21 attributes and the average silhouette was 41 percent. We improved the model, in order to reach a reasonable structure. Finally, based on 7 attributes, a reasonable clustering model was derived. The new model provides 64 percent average silhouette, and based on patients' status, patients are divided into 2 main categories. The risk of HCC in the first cluster is 23 percent and in the second cluster is 14 percent

Epidemiology, associated factors, and treatment experiences with dyspepsia in Iran: a review article

Dyspepsia is a common gastrointestinal symptom reported in 2.9-29% of the adult Iranian population. This symptom usually results from functional disease, but in one-third of cases an organic cause such as peptic ulcers, esophagitis, and in less than one percent gastric cancer can be found. The timing of an endoscopic evaluation, the value of acid reducing agents, herbal medicine and the role of Helicobacter pylori [HP] eradication are important challenges in the evaluation and management of dyspepsia. Overall, prompt endoscopic evaluation for cases over the age of 45 years, those who present with alarm symptoms, or non-responders to empirical acid reducing treatment is recommended. There are controversial results about the role of HP eradication on the relief of dyspepsia symptoms in our region, so the HP test and treatment strategy or eradication therapy for those with functional dyspepsia is not a suitable option for our country. There are promising reports regarding the effects of herbal medicine, and anti-depresants, which needs more research. Due to the limited value of alarm features for diagnosis of gastric cancer, we recommend prompt, low cost endoscopic evaluations in all dyspeptic cases over age 45 years

rare cause of small bowel obstruction in adults: left paraduodenal internal hernia

A 47 years old lady presented with repeated intermittent, colicky, left upper, and periumblical abdominal pain associated with nausea and vomiting since two years prior to admission. Each episode of the pain spontaneously subsided after bilious vomiting. The patient had no history of surgery, abdominal trauma or intra-abdominal infection, weight loss or previous history for small bowel obstruction [SBO]. MRI enterography was suggestive of internal hernia and surgery documented left paraduodenal [mesocolic] internal hernia [LPDIH]. After surgery the patient was followed for three months without any abdominal symptoms

Etiology and outcome of acute gastrointestinal bleeding in Iran: a review article

Upper gastrointestinal bleeding [UGIB] is defined as bleeding that results from lesions located above the ligament of Treitz and is a common cause for emergency hospital admissions in patients with gastrointestinal disorders. UGIB also increases the risk of morbidity and mortality in patients already hospitalized for other reasons. According to epidemiological surveys of acute UGIB in Iran, peptic ulcer is the most common endoscopic diagnosis. Gastric and duodenal erosion accounts for 16.4%-25% of etiologies. Other relatively common causes of UGIB are variceal hemorrhage, Mallory-Weiss tears, and arterial and venous malformations. However, in 9%-13.3% of patients, the endoscopy is normal.

18-year-old man with hepatitis b virus infection and Hepatoblastoma

A young man presented with a large liver mass and positive hepatitis B virus markers. This 18-year-old male has developed ascites, jaundice, high serum alpha fetoprotein [AFP] level, liver mass and portal hypertension, without fever or calcification in the mass. All favored the diagnosis of rapidly, progressive hepatocellular carcinoma, however proven hepatoblastoma in liver biopsy. Hepatoblastoma usually manifests prior to the third year of life, but can rarely be seen in older children or adults. Although HCC rarely can be presented in young patients with HBV infection, but in patients without cirrhosis hepato-blastoma should be considered as the first possible diagnosis

prevalence of gastroesophageal reflux disease [GERD] in the Islamic republic of Iran: a systematic review

Gastroesophageal reflux disease is a common, chronic disease worldwide. The weekly prevalence of reflux in developed countries is 10% to 48%. It has previously been reported as 5% in Asian countries, but new reports show a higher level in both Asian and Arab countries. In Iran, reflux has increased over the last two decades. There are few studies concerning the prevalence of reflux in Iran. This study aims to review reports about the prevalence of reflux in Iran, as it may be different in various parts of the country. By evaluation of the existing articles, this study will reach a general conclusion about the reflux prevalence in Iran. This was a qualitative, systematic review that estimated the prevalence rate of reflux in Iran. In August 2010, we reviewed all electronic database published studies that concerned the epidemiology of reflux prevalence in Iran by searching PubMed, Scientific Information Database [SID], Iran Medex, and Magiran. In our search, using specified key words and selection criteria, 15 articles fulfilled the inclusion criteria and were included in the study. According to the results, the data related to the estimated prevalence in Iran have a wide range. The weekly prevalence rate of 21.2% in the Tehran study is the best estimate for reflux in Iran. It seems that reflux is more common in Iran when compared to other Asian countries, and similar to reflux in Western countries. Due to the absence of comprehensive studies in Iran, we recommend that researchers conduct accurate, comprehensive, multi-dimensional studies in order to estimate reflux prevalence and its burden in Iran

Common digestive and liver diseases among 5880 patients admitted to shariati hospital, Tehran Iran during 2000-2009

Digestive and liver diseases [LD] are among the most common causes of mortality and morbidity in Iran and throughout the world. We have aimed to report the etiology and outcome of gastrointestinal and LD that needed admission in a typical tertiary referral hospital in Tehran during the last decade. Shariati Hospital Gastroenterology and Liver Disease Department [GI and LD] was established in 1974. Information on admitted patients in this department, such as age, gender, clinical, laboratory and imaging results, final diagnosis [according to ICD-10], and hospital outcome have been regularly collected by a special summary form since 1999. For this study, the results were analyzed and compared for two, 5-year time periods, 2000-2004 and 2005-2009. There were 5880 patients [64.60% male] with a mean age of 51.8 years [range: 12 to 90 years] who were admitted. The hospital mortality rate was 6.80%, of which 71.53% were male. The most common cause of hospital admission [39.25%] and mortality [38.55%] was chronic LD. The most common etiologies for admission in both genders were HBV and cryptogenic or non-alcoholic fatty LD [NAFLD] induced cirrhosis of the liver. Other common etiologies were gastrointestinal bleeding, HCV-induced cirrhosis, and CBD stones in male patients; CBD stones, gastrointestinal bleeding and autoimmune hepatitis in female patients. The rate of admission due to HBV-related LD decreased from 21.73% to 11.15%, while admission due to NAFLD-related liver [cryptogenic] disease remained unchanged [11.60% to 10.49%]. The rate of admission for pancreatic cancer increased from 1.71% to 4.56%, CBD stones from 6.96% to 10.22%, cholangitis from 3.37% to 6.93%, acute pancreatitis from 2.54% to 4.65%, and Crohn's disease from 1.93% to 2.72%. End-stage LD secondary to viral, autoimmune and NAFLD constitute the etiology of up to 50% of admissions and mortalities in Shariati Hospital for both genders. While the admission rate of HBV-related LD is declining, the rate of NAFLD-related LD remains stable. The rates of admission for pancreatic cancer, CBD stone, cholangitis, acute pancreatitis and crohn disease increased over the decade

Pepsinogen I and II, gastrin and Cag A serum levels in Shiraz

Despite the similar rate of HP infection, the rate of gastric cancer [GC] differs in different regions of the country. There are conflicting reports for using a panel of serologic tests such as pepsinogens I, II [PG I and PG II], and gastrin for population screening. We designed this study to assess healthy appearing adults in Shiraz, southern Iran in order to evaluate the correlation of these serological tests with demographics and lifestyle in a region with a low rate of gastric malignancy. In a population-based study, 846 out of 1978 subjects who were selected by cluster random sampling based on postal code division in Shiraz agreed to participate in the present study. A questionnaire that included age, gender, weight and height, lifestyle such as physical activity, smoking and the use of nonsteroidal anti inflammatory drugs [NSAIDs] was completed. A blood sample was taken after overnight fasting for measurements of PG I, PG II and Cag A status by enzyme-linked immunosorbant assay [ELISA]. Gastrin level was measured by radioimmunoassay [RIA]. The study included 305 men and 541 women. Their mean age was 50.53 +/- 11.4 [range: 35-99 years]. The level of PG I was significantly more in males than females [116.6 +/- 57.1 vs. 103.1 +/- 55.8, p <0.001], lower in older age groups [p = 0.01], and rural compared with urban residents [110.3 + 55.7 vs 100.2 + 58.1, p = 0.02]. The serum level of PG II was less in obese subjects [p = 0.5]. There was no significant correlation between PG I, PG II, smoking, NSAID use and activity. Gastrin level were not correlated with any of the demographic characteristics. The level of Cag A was significantly different between males and females [30.5 +/- 37 vs. 37.7 +/- 41.7, p< 0.001], more in older subjects [p = 0.007] and non smokers [p = 0.001]. The serum levels of PG I and PG I/PG II ratio decreased significantly in subjects with positive Cag A serology [p < 0.05]. The ratio of PG I/ PG II was lower than 3 in 35 [4.1%] subjects. In this area, the PG I/ PG II ratio is less than 3 in 4% of subjects of which most are positive for Cag A serology and older than 50. We recommend comparison of these findings with high GC mortality regions

Diffuse melanoma of the stomach and duodenum: a case report

Gastrointestinal melanoma [GIM] is occasionally observed in general practice. We report a case of melanoma dispersed diffusely in the stomach and duodenum with no skin involvement

Etiology and outcome of patients with upper gastrointestinal bleeding: a study from South of Iran

The prevalence of acute upper gastrointestinal bleeding [AUGIB] has undergone a change after implementation of eradication therapy for Helicobacter pylori in peptic ulcers effective prevention of esophageal variceal bleeding and eventually, progressive use of low dose aspirin and other nonsteroidal antiinflammatory drugs [NSAIDs]. To evaluate this subject, we performed a prospective study in two main University Hospitals of Shiraz [the largest city of southern Iran]. All adults who were admitted in emergency room with impression of AUGIB and existing patients who developed AUGIB were included in the study. Gastroscopy was done with a follow-up for the next 15 days. 572 patients [mean age: 54.9 years] entered in the study. The most common presenting symptom was hematemesis or coffee-ground vomits [68%]. 75% of patients gave history of consumption of low dose aspirin or other NSAIDs regularly. Gastric and/or duodenal ulcers were the most common causes [252/572, 44%] of AUGIB [Gastric ulcer: 173/572, 30% and duodenal ulcer: 93/572, 16%, respectively]. Esophageal varices were the third common cause [64/572, 11%]. 36 [6%] of the patients died. Mean age of these patients was higher than the patients who were alive [64.8 vs. 54.2 years, P = 0.001]. Other than age, orthostatic hypotension on arrival [267/536 vs. 24/36, P = 0.018] and consumption of steroids [43/536 vs. 10/36, P = 0.001] were significant factors for increasing mortality. The most common cause of AUGIB, secondary only to NSAIDs consumption, is gastric ulcer. Mortality of older patients, patients who consumed NSAIDs and steroids concomitantly, and patients with hemodynamic instability on arrival were higher

long-term immunity among health care workers vaccinated against hepatitis B virus in a large referral hospital in southern Iran

Health care workers are at increased risk of occupational exposure to hepatitis B virus [HBV] infection. Reassessment for revaccination of such high-risk persons after 10 years may be appropriate if anti-HBs antibody titers declined below 10 mIU/mL. This study was conducted to evaluate the long-term efficacy of HBV vaccine in health care workers and the need for their reassessment for revaccination. We interviewed 600 health care workers in a referral hospital in Shiraz, southern Iran. They were asked to complete a confidential questionnaire including information on their age, gender, vaccination date, number of doses of vaccine, their job description in hospital, previous history of needlestick injury, and educational level. Anti-HBs antibodies were determined by the ELISA method and titers of >10 mIU/mL were considered protective. Those with a positive HBsAg or anti-HBcAb were excluded from the study. Among 600 health care workers interviewed, 339 subjects who accepted to participate in the study, were vaccinated with three doses of HBV vaccine. Anti-HBsAb titers were >100 mlU/mL in 211 subjects [62.2%], 10 - 100 mlU/mL in 85 [25.1%], and <10 mIU/mL in 43 [12.7%] persons. Among 339 subjects who received three doses of vaccine, 273 were vaccinated less than 5 years, 47 cases between 5 - 10 years, and 19 cases were vaccinated more than 10 years before the study. The majority of them had an antibody concentration above the protective level [88.1%, 88.9%, and 60.9%, respectively, P = 0.001]. Reassessment for revaccination in health care workers should be considered according to their anti-HBsAb levels 10 years after vaccination. In our health care workers, we think that due to the existence of low immunity against HBV, reassessment for revaccination after 10 years is mandatory