Inflammatory bowel disease and its impact on fertility and pregnancy

The peak age of onset of inflammatory bowel disease [IBD] is simultaneous with the peak reproductive years. Patients have many concerns about the impact of IBD on fertility and pregnancy outcomes. The most important reason for voluntary childlessness is the fear of side effects from medications for IBD. Decision making for medical therapy is a complex equation. It is important to summarize available information about the management of IBD during pregnancy and its interactions. Among IBD patients, those undergoing surgery are at risk for reductions in fertility. Patients with ileal pouches-anal anastomosis [IPAA] experience higher rates of infertility. Disease activity at the time of conception is the main determinant of the impact of IBD on adverse pregnancy outcomes. In different nations, disease activity and relapse depend on many factors and may even be slightly lower during pregnancy. The recommended mode of delivery in IBD is still controversial. However, there is an increased rate of cesarean sections in women with IBD. Choosing the appropriate method of delivery should be based on the obstetrician's opinion, however active perianal disease and the presence of an ileoanal pouch are two major exceptions. If women remain on their maintenance therapy, there would be no increased risk of a flare-up during the postpartum period. In most patients, maintaining remission with medication outweighs the risks of their adverse effects. However, the pros and cons must be discussed with the patient and decisions should be made on an individual basis. Among all drugs used in IBD treatment, only methotrexate [MTX] and thalidomide are contraindicated in pregnancy

[Approach to antiplatelet and anticoagulant therapy before endoscopic procedures]

The use of anticoagulant and antiplatelet agents has become more prevalent during the past decades. These drugs may potentially cause gastrointestinal [GI] bleeding. Thus, there is an increasing need for GI endoscopy in patients who take these medications. In patients who take anticoagulant and antiplatelet agents, the appropriate conditions under which endoscopic procedures should be performed remain unclear. In this manuscript, we reviewed studies regarding this context in an attempt to present a practical guideline for management these patients

[ practical approach to chronic hepatitis B treatment]

Background: Chronic hepatitis B is among the prevalent causes of chronic hepatitis and cirrhosis. The aim of this article is to discuss the indications for treatment, available drugs, and identify drug resistance or intolerance and primary treatment failure in chronic hepatitis B

Materials and Methods: A summary of epidemiology, natural course and treatment options of chronic hepatitis B is presented in this paper according to AASLD practical guidelines for treatment of hepatitis B [2009]. On the basis of serum HBV DNA, alanin aminotransferase and HBe Ag level as well as the liver histological findings the natural course of chronic hepatitis B is divided into four phases: immune tolerance, immune clearance, inactive carrier state and relapse. These phases indicate the patient's immune system activation against the virus and the leading histological liver damage

Results: Patients in immune tolerance and inactive carrier state phases do not need treatment and should only be followed up; while those in immune clearance and relapse phases do need treatment. Selection of PEG IFN or nucleoside analogues should be based on the presence of cirrhosis, viral load and genotype, drug resistance and also the patient's preference. Drug intolerance or resistance can lead to relapse and drug should be stopped or changed in these occasions

Conclusion: Due to the rapid increase of information about chronic hepatitis B treatment and generation of new antiviral medicines, the guidelines for treatment are changing rapidly. Appropriate early treatment decreases mortality and morbidity rate caused by liver disease

[ overview on acute liver failure; prognosis and treatment]

Acute liver failure [ALF] is an uncommon, devastating syndrome of which over 2000 cases occur annually in the USA, with a mortality rate of about 80%. ALF is defined by the sudden onset of hepatic encephalopathy and coagulopathy [INR>/=1.5] in an otherwise healthy person. The most common etiologies are acute viral hepatitis A and B, medication overdose [e.g., acetaminophen] and idiosyncratic drug reactions. The outcome of ALF is determined by its etiology, the degree of hepatic encephalopathy present on admission and by complications, particularly infection. In the era of orthotopic liver transplantation and with improvements in the intensive care of patients with ALF, spontaneous recovery and overall survival now exceed 40% and 65%, respectively. Increased information about the etiologies and treatment options of this syndrome will improve the survival rate of our patients. In this study, we have decided to discuss the main issues of ALF by reviewing the literature and recent papers

[Result and efficacy of endoscopic ultrasound guided FNA in patients with solid pancreatic neoplasm]

Endosonography is a distinct method in evaluating gastrointestinal [GI] structural lesions, particularly in the pancreatobiliary system. This procedure has made a fundamental change in the diagnosis of pancreatic mass lesions through fine needle aspiration [FNA]. This study aims to evaluate the results and efficacy of endosonographic fine needle aspiration [EUS-FNA] in patients presenting with solid pancreatic masses. This was a descriptive, prospective, case series study of patients who presented with solid pancreatic masses to Imam Khomeini Hospital, Tehran, Iran over a one year period [from November 2009-2010] In order to determine false negative cases, patients were followed for 6 to 12 months. A total of 53 patients underwent EUS-FNA with no complications. The results were diagnostic in 46 [87%] cases. The majority of patients were male [68%] and 81% had a mass in the pancreatic head. Cytopathology results revealed 36 [68%] adenocarcinomas, 7 [13%] other malignancies, 3 [6%] benign lesions and 7 [13%] nondiagnostic cases. The frequency of nondiagnostic results was significantly more in masses smaller than 3 cm [6 vs. 1, p < 0.002]. Patients with nondiagnostic results were younger than those with malignant cytopathologies [52 +/- 7.5 vs. 66 +/- 7.5 years, p < 0.001]. Sensitivity, specificity, PPV, NPV and accuracy of EUS-FNA in adenocarcinoma cases were 88%, 100%, 100%, 70% and 90%, respectively. EUS-FNA is an effective and safe procedure in the histopathologic diagnosis of pancreatic tumors

[ frequency of abnormal E-cadherin expression and its relationship with biological behavior of gastric adenocarcinoma]

E-cadherin is a calcium-dependent molecule that contributes to intercellular adhesion. Its proper functioning is important in the maintenance of epithelial structure and integrity. E-cadherin serves as a very important tumor suppressor. In this study, we aim to determine the frequency of E-cadherin expression aberrancy and its relationship to the biological behavior of gastric adenocarcinoma. A total of 52 patients with gastric cancer who underwent gastrectomies in Imam Khomeini Hospital were investigated in a cross-sectional study. Their tissues were stained by immunohistochemistry methods to investigate the expression of E-cadherin. Patients' information including age, gender, Helicobacter pylori infection, lesion location, adenocarcinoma subtype, metastasis, differentiation and regional lymph node involvement, depth of invasion and staging were collected and compared. Age, gender, Helicobacter pylori infection, lesion location, regional lymph node involvement, metastasis, depth of invasion, differentiation and staging did not have a statistically significant relationship with abnormal E-cadherin expression. Abnormal E-cadherin expression was significantly higher in the diffuse sub-type as compared with the intestinal type [90.9% vs. 48.8%, p = 0.016]. The present study assessed the frequency and relationship between abnormal E-cadherin expression and certain biological variables of tumor behavior in Iranian patients with gastric adenocarcinoma. A significant correlation existed only between diffuse sub-typing and reduced E-cadherin expression

[ effect of interleukin 28 B polymorphism on sustained virology response [SVR] in Patients with chronic hepatitis C]

The effect of IL 28 B polymorphism on sustained virology response [SVR] in patients with Hepatitis C genotype 1 varies among races. Multiple studies have shown that the SVR is two or three times higher in patients with CC genotype compared to those with TT genotype. This study aims to assess the relationship between IL 28 B polymorphism and SVR in Iranian patients. Materials and In a cross-sectional study, 48 patients with Hepatitis C genotype 1 who underwent PCR testing six months following treatment were divided into two groups, SVR positive and negative in order to compare IL 28 B polymorphism. The SVR rate was higher in patients who presented with high baseline ALT levels, independent of IL 28 B genotype [p=0.023]. Logistic regression analysis showed a higher SVR rate in patients with CC genotype compared to TT genotype [p=0.007, OR=29.333, CI=2.558-336.387], however no significant difference was noted between TC and TT genotypes [p=0.177, OR=2.887, CI=0.618-13.496]. Additionally, there was a significant difference between CC and non-CC groups [TC, TT] in SVR rate [p=0.017, OR=13.750, CI=1.602- 118.061]. A high SVR rate was seen in the C group [CC, TC] when compared with the TT genotype [p=0.036, OR=4.923, CI=1.111-21.816]. The sensitivity, specificity, PPV and NPV of the IL 28 B genotype in predicting SVR was 88.8%, 38%, 64.8% and 72.8%, respectively. In addition; although the CC genotype was positive, the sensitivity and NPV were increased to 91.6% and 95.2% respectively. This study confirms the relationship between IL 28 B genotype and SVR rate in the patients with Hepatitis C genotype 1. It seems; IL 28 B genotype could be the reasonable Lab. test for treatment plan of the problematic cases of the patients with Chronic Hepatitis C

[Liver mass: an overview on diagnosis]

Liver lesion is a common condition, which often detect incidentally. A large proportion of liver masses can be diagnosed by progression in imaging modalities. Although, definite diagnosis of liver mass's nature can be made by biopsy of lesion and histopathologic examination, but with imaging findings, we can approach to the diagnosis. In this study, we review many valuable articles and scientific references to define main aspects of diagnosis of liver masses

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

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

[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

Comparative study of touch cytology and brush cytology with gastic biopsy and urease test for diagnosis of Helicobacter pylori

Detection of H. pylori, the widely distributed etiologic agent of gastro-duodenal inflammation, peptic ulcer and gastric cancer, is easy and available. In this study, 100 patients who visited endoscopy section of Imam Khomeini Hospital or private clinic in 2001 were studied for gastric cytology [brushing and touch preparation] and biopsy. Of 100 studied patients, 31 patients [31%] had abnormal endoscopy, including gastritis in 78%. Brushing was positive in 43 [43%] patients, touch preparation in 52 [52%], rapid urease test [RUT] in 53% and biopsy in 54[54%] of patients. Sensitivity of brush and touch cytology were 79.6% and96.3%, respectively. Agreement between brush and touch cytology was 78.1%. According to of Mc-Nemar test they had no concordance. Sensitivity of RUT was 98.1%. Agreement between touch cytology and biopsy was 96% and according to Mc-Nemar test they showed concordance

[ frequency of C3435T MDR1 gene polymorphism in Iranian patients with ulcerative colitis]

P-glycoprotein, the product of MDR1 [multi drug resistance] gene, is a trans membrane efflux pump, transferring drugs and toxins from intracellular to extracellular domains. It acts as a protective barrier to keep toxins out of the body by excreting them into the bile, urine and intestinal lumen. In the human gastrointestinal tract, P-glycoprotein is found in high concentrations on the epithelial cells of colon and small intestine. MDR1 gene polymorphism such as C3435T is associated with lower Pglycoprotein expression, thus it is suggested to have an association with ulcerative colitis. We tried to determine the frequency of C3435T polymorphism of MDR1 gene in Iranian patients with ulcerative colitis and compare it with healthy control population. In this case-control designed study, we assessed the C3435T polymorphism of MDR1 gene, in 150 ulcerative colitis patients and 150 sex- and ethnicity-matched healthy controls, who were visited at a teaching hospital during a one year period.[2002-2003]. The extracted leukocyte DNA was amplified by polymerase chain reaction [PCR] with specific primers, and C3435T polymorphism was detected by RFLP method. The mean age of patients was 40.1+/-13.9 years [14-74] and of controls was 40.7+/-14.0 years [16-79]. The frequency of C3435T allele was significantly higher in ulcerative colitis patients compared with controls [OR=1.58, 95% CI= 1.13 - 2.22, p<0.008]. The frequency of C/T genotype was also significantly higher in patients with ulcerative colitis [OR=1.67, 95% CI=1.06-2.64, p<0.028]. This study suggests that the higher frequency of 3435T allele has an association with ulcerative colitis in Iranian population as previously reported in western countries

[Association of the vitamin D receptor gene polymorphisms with inflammatory bowel disease in Iran]

Different genes such as vitamin D receptor [VDR] gene have some roles in IBD susceptibility. Some studies have recognized the relation of VDR gene polymorphisms with inflammatory and autoimmune disorders. Determining the frequency of these polymorphisms and their possible relation with IBD can improve understandings about genetic background of these diseases. The objective of this study was to assess the association of VDR gene polymorphisms [Apa I, Taq I, Bsm I, Fok I] with IBD in Iran. In this case-control designed study 100 UC, 50 CD patients and 150 sex and age matched healthy controls, hospital base, were selected. These patients were referred to [Taleghani Hospital] during a one year period [2004-2005]. Assessment of VDR gene polymorphisms was performed by PCR-RFLP method. Only the frequency of the Fok I polymorphism was significantly higher in UC and CD groups. The frequency of the polymorphic allele f was higher in UC and CD groups comparing with controls [p=0.019, OR=1.581 and p<0.001, OR=2.642, respectively]. The f/f genotype was significantly more frequent in UC and CD patients comparing with controls [p=0.010, OR=2.774 and p<0.001, OR = 5.947, respectively]. There were no significant differences between frequencies in patients and controls in other polymorphisms. There is a relation between Fok I polymorphism in VDR receptor gene and IBD in Iran but no association was observed with other 3 polymorphisms

Nodular regenerative hyperplasia of the liver: report of a case

Nodular regenerative hyperplasia of the liver [NRHL] is characterized by hepatocellular nodules without fibrous septa between the nodules, and has been described in association with certain diseases. The NHRL should be considered in a liver mass and coexisting portal hypertension. We described the case of a 33-year-old Iranian man with NRHL in association with essential thrombocythemia

[ epidemiologic study of microscopic colitis in a university related clinic]

Microscopic colitis has been generally recognized as lymphocytic colitis and collagenous colitis: two inflammatory diseases of large intestine without a definite origin. The colon appears normal by colonoscopy. So, biopsy of the colonic mucosa is mandatory for diagnosis. As a descriptive design we assessed epidemiological, clinical and laboratory findings of patients diagnosed as microscopic colitis from 2001 to 2003, retrospectively. This study had been conducted in one of the University related clinics in Tehran. Results: In this setting, 12 patients were diagnosed as microscopic colitis [3 collagenous colitis, and 9 lymphocytic colitis]. Most of these patients were female [11 patients]. The average of the patients' age at the time of the diagnosis was: 47.6 +/- 18.1 years. The delay of diagnosis was distributed from 2 months to 27 years [average: 8 years]. The most prominent complaint was diarrhea [100%]. Most of the cases were presented as a chronic intermittent manner [6 patients- 50%]. Hyperthyroidism, atrophic gastritis, and type 1 diabetes mellitus, each of them were detected in 3 separate patients. After treatment initiation, recurrence of the disease was not seen during 2 years of follow-up. Most of the time, microscopic colitis is mis-diagnosed as irritable bowel syndrome. Clinical suspicion plays the main role in diagnosis of microscopic colitis cases among patients with watery diarrhea and normal colonoscopy

[Non-alcoholic steatohepatitis [NASH]]

The term "Non- Alcoholic Steatohepatitis [NASH]" is applied when sonographic and pathologic view of liver shows alcoholic hepatitis changes without history of alcohol consumption. Radiologic findings can easily make the diagnosis and liver biopsy confirms the initial suspicion. It is showed that up to 43.5% of patients with asymptomatic abnormal liver transferases levels have some degrees of NASH, which suggest the importance of being familiar with the issue and how to approach and treat it. NASH is commonly accompanied with diabetes mellitus [especially type II], obesity and hyperlipidemia. These findings support the theory in which insulin resistance is the mainstay of NASH pathophysiology. The natural history of NASH is unclear but surely it is far better than alcoholic related liver disease. It is estimated that up to 8% of patients would meet cirrhosis, considering risk factors such as obesity and features found in biopsy specimen. Steatosis, polymorphonuclear lobular inflammation, ballooning degeneration, hyaline- Mallory bodies and cirrhosis are among different pathologies seen in biopsy. It is important to rule out other chronic liver diseases including drug induced liver disease, chronic viral hepatitis, and metabolic and autoimmune liver diseases to establish the diagnosis of NASH. There is no definite treatment for NASH. Therapeutic measures are categorized as reducing risk factors and using hepatocellular protective agents. The former includes weight reduction, treating hyperinsulinemia and diabetes, control of hypertriglyceridemia and leptin. Protective agents are anti-oxidants like vitamin E and/ or C, probucol, silymarin, ursodeoxycholic acid, reducing iron load, N-acetyl cystein, food supplements and cytokines. Increasing rate of NASH is reported among children and adolescences, which could be due to growing amount of obesity in these age groups

[Inflammatory bowel diseases and multiple sclerosis: a look on two cases]

The Inflammatory bowel diseases [IBD] have been found to accompany some neurological syndromes including multiple sclerosis [MS]. Recently, Several studies have reported and discussed the simultaneous presence of IBD and MS in some patients. Thus, in patients with either disease, the presence of signs and symptoms of the other should raise the clinical suspicion of the clinician and warrant special considerations. In this report, we introduce two IBD patients who have concomitant involvement of MS