[Refractory celiac disease; diagnosis, treatment and clinical manifestations]

Celiac disease as an autoimmune disease is predisposes in genetically susceptible subjects due to the consumption of wheat and other grains containing gluten and as a result of immunological responses, villous atrophy, mucosal hyperplasia, and lymphocytic infiltration will be occurred. The only treatment is a lifelong gluten-free diet. Most patients with celiac disease respond to gluten-free diet [GFD]. But in a small percentage of patients, despite full compliance with gluten-free diet, symptoms and mucosal atrophy are remains. When other causes of mucosal atrophy are rejected, the diagnosis of refractory celiac disease [RCD] is suggested. Based on the abnormality in population of intraepithelial lymphocytes [IEL], RCD is divided into two types 1; [RCD I] and type 2 [RCDII]. Prognosis, clinical symptoms and endoscopic findings of RCD I are better and milder than the RCD II. Treatment of RCD I is based on immunosuppressive therapy and RCD II is mostly based on nutritional support and chemotherapeutic agents. In this review the clinical characteristics, diagnostic and treatment approach of RCD will be reviewed

Pathological and clinical correlation between celiac disease and pathological and clinical correlation between celiac disease andpathological and clinical correlation between celiac disease and helicobacter pylori infection; a review of controversial rep

There are overwhelming reports and descriptions about celiac associated disorders. Although there is a clear genetic association between celiac disease [CD] and some gastrointestinal disorders, there are controversial reports claiming an association between CD and Helicobacter pylori [H. pylori] infection. Different studies indicated the possible association between lymphocytic gastritis and both CD and H. pylori infection, although this evidence is not consistently accepted. Also it was shown that an increase in intraepithelial lymphocytes count is associated with both H. pylori infection and celiac disease. Therefore the following questions may raise: how far is this infection actually related to CD?, which are the underlying patho-mechanisms for these associations? what are the clinical implications? what is the management? and what would be the role of gluten free diet in treating these conditions? PubMed [PubMed Central], Ovid, ISI of web knowledge, and Google scholar were searched for full text articles published between 1985 and 2015. The associated keywords were used, and papers described particularly the impact of pathological and clinical correlation between CD and H. pylori infection were identified. In this review we tried to answer the above questions and discussed some of the recent developments in the pathological and clinical aspects of CD and H. pylori infection

relationship between intestinal parasites and some immune-mediated intestinal conditions

Over the last decades, the incidence of infestation by minor parasites has decreased in developed countries. Infectious agents can also suppress autoimmune and allergic disorders. Some investigations show that various protozoa and helminthes are connected with the main immune-mediated intestinal conditions including celiac disease [CD], inflammatory bowel diseases [IBD] and irritable bowel syndrome [IBS]. Celiac disease is a digestive and autoimmune disorder that can damage the small intestine and characterized by a multitude gastrointestinal [GI] and extra GI symptoms. IBD [including ulcerative colitis and Crohn's disease] is a group of inflammatory conditions of the small intestine and colon. The etiology of IBD is unknown, but it may be related to instability in the intestinal microflora that leading to an immoderate inflammatory response to commensal microbiota. Irritable bowel syndrome [IBS] is a common, long-term condition of the digestive system. Bloating, diarrhoea and/or constipation are nonspecific symptoms of IBS. Various studies have shown that some intestinal parasites can effect on immune system of infected hosts and in some cases, they are able to modify and change the host's immune responses, particularly in autoimmune disorders like celiac disease and IBD. The main objective of this review is to investigate the relationship between intestinal parasites and different inflammatory bowel disorders

[Correlation between serum level magnesium and non-alcoholic fatty liver disease]

Non-alcoholic fatty liver disease [NAFLD] was one of prevalent problems in general population. It was the most common cause of abnormal liver function tests and may lead to steatohepatitis and cirrhosis. The role of many factors has been known in NAFLD. In this study, we investigated the correlation of serum magnesium level and NAFLD after minimizing the role of major confounding factors. This was a cross-sectional study in the referral patients to the internal medicine clinic. We grouped study patients in two; patients with and without NAFLD. Then, serum level of magnesium was measured, and its relation was studied between both groups. Within patients enrolled into study, 55 had NAFLD, and 33 were without NAFLD. Both groups were matched for main confounding factors, including: gender, diabetes and metabolic syndrome [p>0.05]. Mean serum magnesium level was 2.26 +/- 0.35, 2.25 +/- 0.39 and 2.08 +/- 0.41 in patients without NAFLD, grade one and two NAFLD, respectively [p=0.06].However it was shown that with each unit increase in serum level of magnesium, risk of fatty liver disease would decrease 50 percent. [OR=0.516, CI=95%, 0.147-1.806]. In the current study, we evaluated the relation between serum magnesium level and NAFLD. We showed that patients with a lower serum level of magnesium have 50% more chance to get NAFLD, and it is correlated with higher degrees of fatty liver disease

Comparison of half-dose and full-dose triple therapy regimens for Helicobacter pylori eradication in patients with end-stage renal disease

The aim of this study was to compare the half-dose and full-dose triple therapy regimens for Helicobacter pylori [Hp] eradication in patients with end-stage renal disease. H. Pylori is one the most important causes of dyspepsia in patients with end-stage renal disease [ESRD]. Sixty-six patients with ESRD were enrolled in the study with Hp infection and peptic disease with a need of Hperadication. Patients were randomly assigned to full-dose [A=35 patients] or half-dose group [B=31 patients]. Patients received clarithromycin 500 mg, amoxicillin 1000 mg and omeprazole 20 mg twice daily in group A and clarithromycin 250 mg and amoxicillin 500 mg twice daily and omeprazole 20 mg once daily in group B for two weeks. Patients provided stool samples 4 weeks of completing study to assess the success of Hp eradication by Hp-specific stool antigen. Finally, the rate of eradication and complications were compared between two groups. The successful Hp eradication was achieved in 26 patients [74%] in group A and in 22 patients [74%] in group B. The difference between 2 groups was not statistically significant [p=0.973] [per protocol analysis]. Half-dose triple-therapy with clarithromycin, amoxicillin and omeprazole is as effective as full-dose triple-therapy to eradicate the Hp in patients with ESRD. According to lower toxicity level, complications and cost in half-dose regimen in this subset of patients, this protocol is advised

Erythromycin decreases the time and improves the quality of EGD in patients with acute upper GI bleeding

To evaluate the efficacy of erythromycin to decrease the time and improves the quality of EGD in patients with acute upper GI bleeding. The diagnostic and therapeutic value of esophagogastroduodenoscopy [EGD] in patients with upper GI bleeding is often limited by the presence of residual blood or clots. Infused erythromycin [3 mg/kg] before EGD, a potent gastro kinetic drug, might improve the quality of EGD in patients with upper GI bleeding and decrease the time of EGD and second- look EGD. In a prospective, randomized, double-blind controlled trial, 40 patients with acute upper gastrointestinal bleeding in Taleghani hospital, Tehran, Iran were studied. The patients were randomized into 2 groups: 1] nasogastric tube placement receiving placebo, and 2] intravenous erythromycin infusion [3mg/kg at 30 min] combined with nasogastric tube placement. The primary end point was endoscopic yield, as assessed by objective and subjective scoring systems and endoscopic duration. Secondary end points were the need for a second look, blood units transfused, and length of hospital stay and mortality. A clear stomach was found more often in the erythromycin group [100% vs. 25%; P< 0.001]. Erythromycin shortened the endoscopic duration [14 vs. 32 minutes in the placebo group; P< 0.001] and reduced the need for second-look endoscopy [1 vs. 3; P< 0.001], admission duration [2 vs 5; P< 0.001] and reduced the blood units transfused [2 vs 4; P< 0.001]. In patients with acute upper GI bleeding, infusion of erythromycin before endoscopy significantly decreases the time and improves the quality of EGD

Gastrointestinal and non-gastrointestinal presentation in patients with celiac disease

Celiac disease [CD] may have a variety of different presentations. This study has aimed to explore the prevalence of gastrointestinal [GI] and non-GI symptoms in patients with CD according to data collected in Italy and Romania [Europe] and Iran [Middle East]. This is a retrospective cross-sectional study conducted in Iran, Romania and Italy with data collection during the period from May 2009 - May 2011. For each center we included only patients with CD that was confirmed by endoscopy, small bowel biopsies and positive serology. GI symptoms such as abdominal pain, diarrhea, constipation, nausea and vomiting, weight loss and flatulence, as well as additional signs and symptoms of iron deficiency anemia [IDA], osteoporosis, hypertransaminasemia, and other related abnormalities were collected. Overall, 323 women and 127 men, whose mean age at diagnosis was 34.2 +/- 16.47 years were included in this study. Of these, 157 subjects [34.9%] reported at least one GI symptom. The majority of cases had the following primary presenting GI symptoms: diarrhea [13.6%], dyspepsia and constipation [4.0%]. Other disease symptoms were reported by 168 [37.3%] patients. The most presenting non-GI symptoms in the majority of cases were anemia [20.7%] and osteopenia [6%]. There were statistically significant differences between the majority of symptoms when we compared the reported clinical symptoms from different countries. This study indicated that upper abdominal disorders such as abdominal pain and dyspepsia were the most common primary complaints among European patients, whereas Iranian patients had complaints of diarrhea and bloating as the classic presentations of CD. For non-GI symptoms, anemia was the most frequent complaint for both Iranian and Italian patients; however it was significantly higher in Iranians

Gluten associated dyspepsia; serology and histological characteristics

The aim of this study was to assess the prevalence of celiac disease [CD] in dyspeptic patients. Although severe mucosal abnormality with villous atrophy [lesions Marsh III] is the histology gold standard for the diagnosis of CD, non-specific microenteropathy [Marsh I-II] with positive serology is also common Patients with dyspepsia, specific CD antibodies and microenteropathy, could have CD. From November 2007 to October 2008, 407 randomly chosen patients who underwent diagnostic upper gastrointestinal endoscopy for dyspeptic symptoms [193 male, 214 women; mean age 36.1 years] were studied. Small bowel biopsies were performed in all of them. Histologic characteristics in duodenal biopsy specimens for CD were evaluated according to the modified Marsh Classification. All the patients were also tested for serum total immunoglobulin A and anti-transglutaminase [tTG] antibodies. Those with IgA deficiency were tested for IgG tTG. Duodenal histology showed Marsh I-IIIc lesions in 6.4% cases. 4 patients [0.98%] were IgA deficient and none of them were positive for IgG tTG. Serology showed positive results for tTGA in 8% of the patients and 2.5% of them had abnormal histology [Marsh I-IIIc] compatible with CD. The results of this study showed that milder enteropathy [Marsh 0-II] have a low specificity for CD. The prevalence of CD among dyspeptic individuals is significantly [2.5%] higher than in the general population [1%] and CD should be investigated in these patients

Frequency of hepatitis C in patients with rheumatoid arthritis

Hepatitis C virus [HCV] infection has been explained as a disease that sometimes present with rheumatic manifestations indistinguishable from rheumatoid arthritis. This study has been performed to evaluate the frequency of hepatitis C virus infection in a group of patients with rheumatoid arthritis. In this study, during one year, serum samples collected from two hundred consecutive patients with rheumatoid arthritis in all affiliated hospitals of Shaheed Beheshti University, MC., were examined for anti-HCV antibody and HCV-RNA by ELISA and RT-PCR method, respectively. Using a questionnaire, the frequency of HCV infection, age and sex distribution, duration of rheumatoid arthritis, associated immune mediated disorders and risk factors for hepatitis C virus infection were assessed. A total of 200 patients [M/F=26/174] who were mainly aged 51-70 years were studied. The frequency of HCV was found to be 2% [95%CI: 0.6-7%]. All of the infected persons have had a low risk occupation in terms of exposure to the virus and none of them had HCV risk factors. No associated immune mediated disorder was found in HCV infected patients. Our results did not support any contribution of HCV infection in the pathogenesis of rheumatoid arthriti

Seroprevalence of anti-helicobacter pylori antibodies in hepatitis B and C patients with cirrhosis: a case-control study

Cirrhosis is terminal stage of many chronic liver diseases like hepatitis C and hepatitis B. In some studies the role of helicobacter pylori has been demonstrated in progress of cirrhosis and its complications, but none of the previous studies has investigated the role of socioeconomic conditions of patients in childhood period in this issue. In a case-control study, we examined 100 cirrhotic patients due to hepatitis [49 hepatitis B and 51 hepatitis C patients] and 101 socioeconomically matched healthy controls presenting to Taleghani Hospital for IgG antibody to helicobacter pylori. IgG antibody to helicobacter pylori was present in 73% of cirrhotic patients and 52% of control group [P < 0.003]. Odds ratio for the presence of IgG antibody to helicobacter pylori in cirrhotic men comparing with healthy men was 3.2 [95%CI: 1.4-7.4]. The relative frequency of IgG antibody to helicobacter pylori found to be higher in cirrhotic patients than in controls with regard to socioeconomic condition in childhood

Abdominal pain due to lead-contaminated opium: a new source of inorganic lead poisoning in Iran

Although the incidence of occupational and adult lead poisoning has declined, the problem still exists. We encountered three patients with lead poisoning in Iran, all of whom associated with presented with diffuse abdominal pain, which was at times colicky in nature, anemia, constipation, nausea, vomiting, and slightly abnormal liver biochemistries. A history of opium ingestion was present in each of these patients. None of the patients reported known occupational exposure to toxins. Diagnoses of lead poisoning were confirmed through the detection of elevated blood lead levels. The cause of lead poisoning was attributed to the ingestion of contaminated opium. Opium adulterated with lead had not been previously recognized as a source of lead poisoning in Iran. It is, therefore, pointed out that lead poisoning should be considered as a differential diagnosis for acute abdominal colic of unclear cause in patients with opium addiction