Iranian Registry of Crohn's and Colitis: study profile of first nation-wide inflammatory bowel disease registry in Middle East

BACKGROUND/AIMS: A recent study revealed increasing incidence and prevalence of inflammatory bowel disease (IBD) in Iran. The Iranian Registry of Crohn's and Colitis (IRCC) was designed recently to answer the needs. We reported the design, methods of data collection, and aims of IRCC in this paper. METHODS: IRCC is a multicenter prospective registry, which is established with collaboration of more than 100 gastroenterologists from different provinces of Iran. Minimum data set for IRCC was defined according to an international consensus on standard set of outcomes for IBD. A pilot feasibility study was performed on 553 IBD patients with a web-based questionnaire. The reliability of questionnaire evaluated by Cronbach's α. RESULTS: All sections of questionnaire had Cronbach's α of more than 0.6. In pilot study, 312 of participants (56.4%) were male and mean age was 38 years (standard deviation=12.8) and 378 patients (68.35%) had ulcerative colitis, 303 subjects (54,7%) had college education and 358 patients (64.74%) were of Fars ethnicity. We found that 68 (12.3%), 44 (7.9%), and 13 (2.3%) of participants were smokers, hookah and opium users, respectively. History of appendectomy was reported in 58 of patients (10.48%). The most common medication was 5-aminosalicylate (94.39%). CONCLUSIONS: To the best of our knowledge, IRCC is the first national IBD registry in the Middle East and could become a reliable infrastructure for national and international research on IBD. IRCC will improve the quality of care of IBD patients and provide national information for policy makers to better plan for controlling IBD in Iran.

Association between Helicobacter pylori infection and alopecia areata: a study in Iranian population

Background: alopecia areata is an immune mediated inflammatory hair loss, which occurs in all ethnic and age groups, and both sexes. However no significant etiology has been known for this disease.Helicobacter pylori [H. pylori], is an organism colonized in gastric mucosa. This bacterium has been associated with certain extra-digestive dermatological conditions. The causal relationship between alopecia areata and H. pylori infection has been discussed in literature. Therefore, we conducted this study to evaluate the prevalence of H. pylori infection in patients with alopecia areata and assess the risk of this infection in patients with this disease in order to determine its potential roles in the physiopathology of this disease

Methods: between 2014 and 2015, we prospectively studied 81 patients with alopecia areata and 81 healthy volunteers with similar age and sex. Patients without any history of H. pylori infection were included in the study and underwent urease breath test. All results were analyzed using SPSS software [version 21.0] and p value<0.05 was considered as statistically significant

Results: 81 patients and 81 controls with the mean age of 34.9+/-11.6 and 38.2+/-13.4 years were studied [p=0.097]. 48 [59.3%] and 45 [55.6%] individuals were male, in cases and control groups respectively [p =0.634]. The result of urea breath test [UBT] was positive in 43 [53.1%] patients in cases and 27 [33.3%] individuals in control group, which was significantly different [p =0.011]. The risk of H. pylori infection in alopecia areata was 2.263 [95% CI: 1.199-4.273]

Conclusion: the results of our study showed significant difference between H. pylori infection in individuals with and without alopecia areata, which shows that H. pylori contamination may be effective in physiopathology of alopecia areata. Therefore these results should be tested in large multivariable cohorts and controlled trials to reach more accurate evidence in the future and to generalize this idea to larger population

diagnostic role of magnetic resonance enterography as a complementary test to colonoscopy in active Crohn's disease

Background: According to recent studies comparing magnetic resonance enterography [MRE] with ileocolonoscopy for assessing inflammation of small bowel and colonic segments in adults with active Crohn's disease [CD], we aimed to compare the accuracy of these two diagnostic methods in Iranian population

Method: During 2013-2014 a follow-up study was done on 30 patients with active CD ina gastroenterology clinic affiliated to Tehran University of Medical Sciences. MRE and ileocolonoscopy were performed for all the patients. All statistical analyses were performed using SPSS [version 18] and P value<0.05 was considered as statistically significant

Results: Of the 30 patients with active CD, 11[36.7%] were men and 19 [63.3%] were women with mean age of 37.30 +/- 13.66 years [range: 19-67 years]. MRE had sensitivity and specificity of 50% and 90% with positive predictive value [PPV] and negative predictive value [NPV] of 71.43 and 78.26, respectively for localizing sigmoid lesions and ileum had sensitivity and specificity of 84.21 and 45.45 with PPV and NPV of 72.73 and 62.50, respectively

Conclusion: While moderate sensitivity and high specificity of MRE in localizing colonic lesions makes it an appropriate confirmatory test after colonoscopy, the reported high sensitivity and moderate specificity of MRE versus colonoscopy in detecting ileal lesions makes it a suitable screening test for ileal lesions. Finally we can conclude that MRE can be an important complementary test to colonoscopy in detecting active disease

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

Accuracy of 99mTc [V]-dimercaptosuccinic acid scintigraphy and fecal calprotectin compared with colonoscopy in localizing active lesions in inflammatory bowel disease

Introduction: Due to limitation of colonoscopy in assessing the entire bowel and patients' intolerance in inflammatory bowel disease [IBD], in the current study, we aimed to prospectively compare the accuracy of [99m]Tc[V]-dimercaptosuccinic acid [DMSA] and fecal calprotectin with ileocolonoscopy as new methods for localizing inflammations

Methods: Current prospective study conducted between 2012 and 2014 on 30 patients with IBD attending Gastroenterology Clinic of Tehran University of Medical Sciences. Fecal calprotectin and disease activity were measured for all participants and all of them underwent [99m]Tc [V]-DMSA scintigraphy and colonoscopy. The accuracy of [99m]Tc [V]-DMSA scintigraphy and calprotectin in localizing bowel lesions were calculated

Results: A total of 22 patients with ulcerative colitis [UC] and 8 patients with Crohn's disease [CD] were evaluated in our study. Sensitivity, positive likelihood ratio [PLR], and positive predictive value [PPV] of scintigraphy and calprotectin over colonoscopy in localization of UC lesions were 86.36%, 0.86%, 100.00% and 90.91%, 0.91, and 100.00%, respectively. Meanwhile, it showed 66.67% sensitivity and 81.25% specificity with PLR=3.56, negative likelihood ratio [NLR]=0.41, PPV=84.21%, and negative predictive value [NPV]= 61.90% in localizing lesions in patients with CD. The calprotectin level had sensitivity, PLR, and PPV of 90.00%, 0.90, and 100.00% in detecting active disease over colonoscopy, respectively

Conclusion: The [99m]Tc [V]-DMSA scintigraphy would be an accurate method for detecting active inflammation in follow-up of patients with IBD and assessing response to treatment as a non-invasive and complementary method beside colonoscopy for more accurate diagnosis of CD or UC

Survey on migraine prevalence in patients with inflammatory bowel disease - a single centre experience

Background: It is hypothesized that migraine may be related to inflammatory bowel disease [IBD], therefore in this cross-sectional study we evaluated the prevalence of migraine in patients with IBD

Methods: In this cross-sectional study 80 patients with IBD and 80 patients without IBD referring to a private gastroenterology clinic from May to January 2014 were evaluated regarding the prevalence of migraine, severity of migraine based on Headache Impact Test [HIT-6], and habits related to headache

Results: 160 participants with the mean age of 35 years were evaluated. The prevalence of migraine in the case group was significantly higher than the control [21.3% vs. 8.8%,p=0.027]

Moreover, duration of each attack [hours] in IBD group was significantly higher than the control group [K0.001] while the duration of migraine involvement [months] and number of attacks was higher in the control group [p=0.019 and 0.048, respectively]

Headache other than migraine in the control group was significantly higher than the IBD group [p=0.00l]

Disability in the case group was more than the control group but the difference was not significant. The correlation between the severity of disability related to migraine [based on HIT-6] and severity of IBD [based on Mayo score and Crohn's disease activity index [CDAI]] was not significant [r=0.16, p=0.58]. Moreover the correlation between the duration of IBD and migraine prevalence was not significant [r=-0.14, p=Q. 19]

Conclusion: We found that the prevalence of migraine in patients with IBD is significantly more than normal population. More studies are needed to highlight the correlation between migraine and IBD

review of the etiology, diagnosis and management of halitosis

Halitosis generally refers to the unpleasant odor of breath irrespective of its origin. Oral malodour could result in diverse problems in daily life such as social embarrassment and can adversely affect individuals' social interactions. Though many oral and non-oral sources could give rise to halitosis, it was mainly associated with oral cavity conditions and volatile sulfur compounds -produced by microbial activity- were the main elements of oral malodor. Objective measurement was the first step in assessment to determine presence of malodour. Then, taken a complete history including diet and habit history and performing a comprehensive physical examination contribute to the primary two steps for evaluating a patient complaining. The oral malodor management was mainly achieved by determining and eliminating the etiology of the condition. A major step in this regard was improving the oral health by means of establishing appropriate oral hygiene measures and controlling tongue flora by brushing or scraping and also, use of antiseptics as adjuvant therapy. Current article was systematic reviews the literature on prevalence, classification, diagnosis and treatment of halitosis

Peripheral neuropathy in ulcerative colitis: a case report

Inflammatory bowel diseases [IBD] were systemic disorders involving many organ systems. Besides intestinal manifestations, extra intestinal manifestations [EIMs] including neurologic complications have been reported among 6%-40% of IBD patients. Ulcerative colitis [UC] was a subtype of IBD only affecting the colonic mucosa and sub mucosa. Although the EIMs of UC could affect any organ system, central and peripheral neurological manifestations were relatively rare. Here, we described a case of UC and concurrent primary sclerosing cholangitis [PSC] who complained about paresthesia and weakness of his upper and lower limbs for the past two months. Through physical examination revealed decreased muscle tone in his legs and arms. Electrophysiological studies were compatible with the diagnosis of chronic mixed polyneuropathy which improved after administration of intravenous immunoglobulin [IVIG] and the patient was discharged in good general condition. Although both immunologic and non-immunologic mechanisms we considered to play a role in development of neuropathies, further investigations were still required to accurately understand the underlying mechanism

44 year old woman with acute pancreatitis and confusion: case report study

Wernike encephalopathy[WE]caused by thiamine deficiency was a critical but reversible disorder. It can be occurred after acute pancreatitis due to prolonged fasting. WE after acute pancreatitis was rarely suspected and diagnosed at early stages. We reported a 44 year-old woman with severe acute pancreatitis who developed altered mental status and bilateral nystagmus and ophthalmoplegia soon after 14 days of fasting. The brain MRI confirmed the diagnosis. After empiric treatment with thiamine all of the neurological symptoms reversed except only some antegrade and retrograde amnesia. In this case report considering thiamine deficiency in any patients with fasting and neurological symptoms, was addressed since WE was a reversible disorder if it was diagnosed in early stage

Review of barrett's oesophagus to oesophageal adenocarcinoma: new prospect

Today's knowledge on oesophageal adenocarcinoma and its rising incidence has encouraged researcher to illustrate relationship between Barrett's disease and progression to adenocarcinoma. The incidence of this disease has been accelerated sharply in current decades since people life has changed. Studies have been demonstrated that several potential factors including genetical and environmental factors are involved on Barrett's transformation. Using different detectable biomarkers and techniques have supported early recognition of adenocarcinoma but still have not clarified pathogenesis of Barrett's oesophagus to oesophageal adenocarcinoma. This review summarizes as much as information in relationship with those evidences that have been finalised in different aspects of cellular and molecular pathogenesis of OA. However, current data shows that bacteria might play new role in the pathogenesis of adenocarcinoma

[Effectiveness of biofeedback on quality of life in patients with dyssynergic defecation disorder]

Dyssynergic defecation disorder [DD] has recognized as the main factor for chronic functional constipation. This was a debilitating disease effective on diverse aspects of physical, psychological and social functions as well as patients' quality of life generally. Modern studies show positive impact of biofeedback therapy on dyssynergic defecation. This study was evaluated the efficacy of biofeedback on quality of life in patients with dyssynergic defecation. A total of 30 patients with dyssynergic defecation disorder visited tertiary care centers who were selected. Among them, 15 subjects underwent 8 biofeedback therapy sessions as experimental group and remaining subjects were placed into control group without biofeedback intervention. Both groups participated in pre-test and post-test of 36-item short form survey [SF-36] of quality of life. Data were analyzed and compared by analysis of covariance [ANCOVA]. Findings shows that biofeedback therapy was effective on quality of life patients with dyssynergic defecation [p= 0.001] Also, index effect suggested that 53% increased of QOL patients with dyssynergic defecation in experimental group can be related to biofeedback therapy. Also in 8 cases, results indicated that biofeedback therapy was effect on quality of life in patients with DD [p<0.05]. Given the results in this study, biofeedback is a long-term effective method to treat with limited side effects in dyssynergic defecation and patients QOL

survay case of pylephlebitis associated with diverticulitis

Pylephlebitis was a rare condition with high rates of morbidity and mortality. It is defined as thrombosis of the hepatic and portal veins that complicates intra-abdominal infections, however prompt diagnosis plays a significant role in the treatment of pylephlebitis and the disorder can be diagnosed by means of ultrasound or contrast tomography, it was often missed due to nonspecific clinical presentation including fever, abdominal discomfort and fatigue. When it came to treatment, despite controversies about the use of anticoagulants, administration of antibiotics and anticoagulants was still the mainstay of treatment. In this report, we described a 67-year-old man with chief complaint of bouts of high fevers and mild abdominal tenderness located in right lower quadrant. The patient suffered from pylephlebitis secondary to cecal diverticulitis. Our patient's symptoms did not resolve with antibiotic therapy thus he had surgical resection of the infection focus and received anticoagulation. To put in a nutshell, as early diagnosis and treatment are essential steps for proper management of pylephlebitis and preventing its adverse complications, it is of high importance to keep this differential diagnosis in mind in patients with abdominal sepsis sings

[ relationship between sexual function and quality of life in patients with irritable bowel syndrome]

Sexual dysfunction is common in chronic diseases such as irritable bowel syndrome [IBS]. Sexual function is an important aspect of quality of life. The present study seeks to determine the relationship between sexual function and quality of life in patients with IBS. In this cross-sectional study, 47 female patients with IBS who referred to the one of gastroenterologist clinics in Tehran and gastroenterologist clinic at Imam Khomeini Hospital selected via the available sampling method. Patients completed the Irritable Bowel Syndrome Quality Of Life questionnaire [IBS-QOL] and Female Sexual Function Index [FSFI]. Data were analyzed by Pearson correlation models. According to the IBS-QOL, patients' mean score for quality of life [121.9] was poor. The FSFI mean score was indicative of sexual dysfunction. We observed a significant correlation between sexual function and quality of life in patients with IBS [p<0.05]. There was a significant correlation between dyspareunia and quality of life in patients with IBS [p<0.05]. This study showed the presence of a relationship between sexual function and quality of life in patients with IBS. Therefore appropriate strategies for education and counseling should be adopted, as well as referral to a psychologist or psychiatrist for sexual health promotion to improve the quality of life in patients with IBS.

case of rhabdomyolysis associated with peginterferon use in chronic hepatitis C

Rhabdomyolysis is a serious clinical condition resulting from release of toxic intracellular materials into the systemic circulation. Multiple factors have been demonstrated to be responsible for this syndrome. However, currently medications and alcohol are considered to be the primary causative agents. To the best of our knowledge there are few reported cases of rhabdomyolysis following prescription of peginterferon alfa-2b in patients with chronic hepatitis. Here, we have reported the case of a 46-year-old male with hepatitis C virus [HCV] infection who suffered an acute onset of generalized myalgia and weakness, with elevated serum creatine phosphokinase [CPK] and lactate dehydrogenase [LDH] levels six months after administration of peginterferon alfa-2b. Considering the clinical picture and laboratory findings, we diagnosed the patient with rhabdomyolysis. Peginterferon alfa-2b and ribavirin were discontinued and intensive intravenous hydration commenced. Within ten days the patient improved significantly after which he was discharged in an appropriate physical condition.

[Predicting quality of life on the basis of type d personality in patients with irritable bowel syndrome]

Quality of life is a main outcome in psychosomatic disorders. Several psychological factors are mentioned for predicting the quality of life in patients who suffer from irritable bowel syndrome [IBS]. The aim of this study is to determine the relationship between type D personality and quality of life in patients with IBS. This study enrolled 90 [52 women] IBS patients who referred to the gastroenterology clinics of Imam Khomeini and Laleh hospitals from September to December 2012. We used the Type D Personality and IBS Quality of Life questionnaires to evaluate patients. Data were analyzed by Pearson correlation and multi-variable regression models. Overall, 61% of patients were H. pylori positive. The mean anti-Thyroid peroxidase level in the H. pylori positive group We observed a relationship between type D personality and quality of life in patients with IBS [r=0.504, p<0.01]. The results showed a 26% variation in quality of life predicted by type D personality [p<0.01, R[2]=0.26]. According to the results, type D personality is one of the predictors of quality of life in patients with IBS. Therefore, it is important to consider psychological factors when choosing the appropriate treatment for IBS patients.

overview on inflammatory bowel disease treatment

Inflammatory bowel disease [IBD] is a chronic relapsing, idiopathic disorder of the gastrointestinal tract of an unknown etiology. Ulcerative colitis [UC] and Crohn's disease [CD] have become important health problems. Current medical therapy of IBD has advanced dramatically with the introduction of new biologic therapies in addition to the optimization of conventional therapies that include drugs such as immunosuppressors and 5-aminosalicylic acid [5-ASA], and a better identification of factors involved in the pathogenesis of IBD. The aim of this review is to provide a brief historical perspective of the available evidence for the use of various medications in IBD followed by a recent literature update. The intent is to enhance the clinician's perspective regarding IBD treatment.

case of kindler syndrome presenting with dysphagia

Kindler syndrome is a rare hereditary disorder that predominantly involves the skin and mucous membrane. Acral skin blistering, progressive photosensivity, skin atrophy and poikiloderma that begin from infancy and childhood are considered to be characteristic manifestations. Urethral, anal, esophageal, mouth and laryngeal mucosa may be involved in this syndrome, thus periodontitis and gingival involvement, anal, esophageal or urethral strictures may be present in this disease. Although gastrointestinal tract involvement in patients with Kindler syndrome is possible, it is rare in the literature. We report the case of a 34-year-old male with Kindler syndrome who had referred with dysphagia. Upper gastrointestinal endoscopy revealed an esophageal web in the upper third of the esophagus. Endoscopic dilatation of the esophageal web was performed by using a mechanical dilating bougie. Two months after esophageal dilatation we found significant improvement in the patient's dysphagia according to the validated Mayo Dysphagia Questionnaire [MDQ].

[Predicting quality of life on the basis of illness perception in patients with irritable bowel syndrome]

Irritable bowel syndrome [IBS] is a disorder of the gastrointestinal system that presents with special gastrointestinal signs and lack of an organic etiology. Quality of life [QOL] is one of the most important outcomes of IBS. Several psychological factors are mentioned as effective in determining QOL in IBS patients. The goal of this study is to determined the relationship between illness perception and QOL in patients with IBS. This study enrolled 96 patients, 40 males[41.7%] and 56 females[58.3%] who referred to the gastroenterology clinics of Imam Khomeini and Laleh hospitals from September to December 2012 Tehran, Iran. Participants completed a Brief Illness Perception Questionnaire [Brief- IPQ] and an IBS-specific QOL [IBS-QOL-34] questionnaire. Information collected by the questionnaire were analyzed with Pearson'scorrelation and regression analysis. Results of the analysis performed by Pearson's correlation showed a significant association between patient's illness perception and QOL among those with IBS. Among the subscales of illness perception, the Consequence [p<0.01, r=0.63], Emotion [p<0.01, r=0.55], Concern [p<0.01,r=0.31], Timeline[p<0.01,r=0.30], and Identity [p<0.01,r=0.20] subscales showed the most significant correlation with QOL. There was no relation observed between Illness Comprehensibility, Treatment Control, and Personal Control subscales with QOL. Patient's illness perception seems to play a role in determining QOL among IBS suffers. Therefore psychological intervention based on the patient's illness perception is recommended for IBS patients

Update on the management of ulcerative colitis

The present treatment goals for inflammatory bowel diseases [IBD] especially ulcerative colitis [UC] include rapid induction of clinical remission, steroid-free maintenance of clinical remission, mucosal healing and improvement of quality of life in UC patients. Immunomodulators have been reserved for steroiddependent or steroid- refractory UC patients. Among these agents, azathioprine/6-mercaptopurine should be used for maintenance of remission in quiescent UC. Calcineurin inhibitors can be prescribed as a short-term rescue therapy in steroid- refractory UC patients, but the long term efficacy of these agents remains unclear. According to retrospective studies, methotraxate is not recommended for inducing and maintaining remission in UC. Novel biological therapies targeting different specific immunological pathways continue to be developed and introduced for a variety of clinical scenarios in IBD. Infliximab is currently used for induction and maintenance therapy in patients who have moderately to severely active UC with an inadequate response to conventional agents such as aminosalicylates, corticosteroids, or immunomodulators. Other anti-TNF agents and biologic therapies are undergoing evaluation in clinical trials for their efficacy in IBD. Most patients who start biologics should continue treatment for the foreseeable future and potential consequences of discontinuation should be discussed with individual patients. Currently, data do not exist to administer biologics as first-line therapy in UC. Emerging data suggest that biologics may have the potential to prevent complications and limit disease progression. If such benefits are proven, biologics may be used in the future to modulate subclinical inflammation and to prevent the development of clinical disease

Report of a case with small bowel obstruction by a rare parasite [Pentastomiasis]

Linguatula serrata [L. serrata], an aberrant arthropod of the Pentastomida phylum, inhabits the canine respiratory system as its final host. Intermediate hosts include humans and herbivores. Humans can be infected via consumption of raw or under-cooked liver or lymph nodes of sheep, goats, and cattle. A few human cases have been reported from Iran. Here, we have reported a case of pentastomiasis infection in a 55-year-old man who presented with fever, abdominal pain, abdominal distension, and weight loss. Small bowel transit revealed partial obstruction in the small intestine. Abdominal CT scan showed increased small bowel wall thickness. Both laparoscopy and biopsy findings favored parasitic granuloma from a pentastomiasis infection. He was administered praziquantel and albendazole. After two weeks of therapy the patient recovered