Comparison of levofloxacin-based, 10-day sequential therapy with 14-day quadruple therapy for helicobacter pylori eradication: a randomized clinical trial

Background: Considering the importance of Helicobacter pylori [H. pylori] eradication, this clinical trial was designed to prospectively evaluate the efficacy of levofloxacin-based, sequential therapy in comparison with quadruple therapy for eradicating H. pylori

Methods: Overall 156 patients with dyspepsia and H. pylori infection were included in this study and were randomly allocated to either 10-day sequential therapy group [group A] to receive pantoprazole [40 mg twice daily], amoxicillin [1 gr twice daily], levofloxacin [500 mg twice daily], and tinidazole [500 mg twice daily] [PALT] or 14-day quadruple therapy group [group B] to receive pantoprazole, clarithromycin, bismuth subcitrate, and amoxicillin [PABC]. At the end of the study the eradication rate in each group was assessed by urea breath test [UBT]

Results: Age range of the participants was 18-65 years [average 36.9 years] and 50% of them [78 patients] were men. 78 patients were allocated to group A and 78 patients to groupe B. After antibiotic therapy, all the patients received acid suppression therapy with Proton Pump Inhibitor [PPI] for 4 weeks and then the eradication rate was confirmed by UBT [Heli FAN plus 13C, Germany]. Before performing UBT, all the participants were requested to halt consumption of PPI for at least 1 week. During the treatment there was not any major complication but in group A [sequential therapy], two patients complained of minor complications including musculoskeletal pain. None of the patients in group B had any complaint or side effect.The rate of H. pylori eradication in group A was 78.2% [61 patients] while this rate in group B was 83.3% [65 patients] with no significant difference between the two groups [p = 0.42]. In subgroup analysis, the rate of eradication among men in group A and B were 76.9% and 89.7%, respectively [p = 0.22] while the eradication rate among women were 79.4% and 76.9%, respectively [p = 1.00]

Conclusion: It seems that levofloxacin base sequential therapy does not have any advantage in comparison with quadruple regimen and until finding any more effective short course therapy for H. Pylori eradication; we encourage quadruple regimen to be used as the first line therapy

Role of air pollution in inflammatory bowel disease flares: a retrospective study

Background: To evaluate relation between air pollution and rate of flare and hospital admission among inflammatory bowel disease [IBD] patients

Materials and Methods: In this retrospective study, during a 10 months period, the number and average duration of hospitalization of patients admitted in GI ward due to IBD flare were recorded in an industrial capital city. Concomitantly the level of 4 major air pollutants including SO[2], CO, NO[2] and O[3] measured and the correlation between severity of IBD flare and air pollution determined by Pearson correlation coefficient

Results: Average number of admission was 7 patients per month [1-12]. This figure for Crohn's disease [CD] was 2.9 and 3.7 for ulcerative colitis [UC]. The average duration of hospitalization for UC and CD were 2.8 days [1-13] and 2.9 days [1-22] respectively. After comparison of average concentration of 4 major air pollutants with rate of IBD flare, there was a relation, although non-meaningful, between CO concentration and number and duration of admissions due to UC flare [p=0.135 and 0.08, correlation coefficient 0.196 and 0.251 respectively]. DATA analysis did not reveal any significant relation between SO[2] and NO[2] and the rate of admission due to IBD flare [p>0.05] and Interestingly there were a reverse meaningful correlation between concentration of O[3] and number and duration of admissions due to Crohn's disease flare [p=0.016 and 0.006, Correlation Coefficient-0.338 and -0.413 respectively]

Conclusion: It seems that CO as one of the major air pollutants can aggravates course of ulcerative colitis and on the other hand O[3] could have a potential protective effect on Crohn's disease. This issue should further be clarified in future studies

Acute pancreatitis complicated by vascular emboli

This was a case of acute pancreatitis who complicated by left side hemiplegia and dysarthria. It diagnosed as Lacunar infarction and therapy with intravenous heparin started according to neurologist order. In third day of admission, the patient suddenly got dyspnea, tachycardia and tachypnea. Infusion of heparin continued with clinical diagnosis of pulmonary emboli and also warfarin added to his therapeutic regimen. The clinical condition of patient gradually got better and on 7th day of admission, he could tolerate oral regimen without any respiratory difficulty and his hemiplegia improved. On the following day, he discharged from ward with prescription of warfarin

case-control study on occult hepatitis b infection in chronic hemodialysis patients from south-west of Iran

Blood born viral infections such as hepatitis B virus [HBV] are major concerns in chronic hemodialysis [CHD] patients and hemodialysis units. Undetected HB[s] Ag in the presence of viral DNA, occult HBV infection [OBI], isa concern in the care of CHD patients and hemodialysis unit as a mode of transmission.In this case-control study we compare the frequency of OBI in the CHD patients with the normal population.82 consecutive CHD patients and 82 healthy individuals without any risk factors for HBV infection were enrolled in this study. A selection criterion was negative serum HB[s] Ag by ELISA method. Subsequently, the sera were tested for HBV DNA by nested PCR method.In the CHD group, 55 [67.1%] were male and 27 [32.9%] were female, with the overall mean age of 54.32 +/- 13.67 years old. The mean age of control group was 32.65 +/- 8.51 years old, with 26 [31.7%] male and 56 female [69.3%]. HBV DNA was present in 9 [11%] CHD patients, 4 [8%] of whom were seronegative for anti-HBc and anti-HB[s] antibodies. No HBV DNA was identified in the control group [p<0.0001]. History of blood transfusion was presentin all OBI CHD patients and 59 [80.9%] of non-OBI CHD patients. Duration of hemodialysis in OBI CHD and non-OBI CHD patients were 73.56 +/- 39.53 and 44.24 +/- 24.59 months, respectively [p =0.002]. The prevalence of occult HBV infection is relatively high in patients with chronic hemodialysis in our region. Duration of hemodialysis and history of blood transfusion are important risk factor for OBI infection. A more sensitive method, such as PCR, may need to be considered in this patient population

Epidemiologic and demographic survey of celiac disease in khuzestan province

BACKGROUND: Celiac disease presents with a wide spectrum of symptoms

This study clarifies different aspects of celiac disease along with the most common patterns of celiac presentation in Khuzestan Province, Iran

METHODS: Patients' information was obtained by evaluation of their files from the archives of the Khuzestan Celiac Society and records at gastroenterologists' offices in this province

RESULTS: Overall, there were 103 [40 males, 63 females] patients included in this study. Patients' mean ages were 33 +/-11 years [males] and 31.6 +/- 11.7 years [females]. In terms of geographic distribution, 54.1% resided in the center of the province followed by 26.5% who were residents of the northern area. The rate of employment among men was 70.6% whereas it was 8.3% for women. In terms of education, 21.9% of men and 33.3% of women had academic educations. The rate of matrimony was 80.6% [n=29] for men, 65.4% [n=38] for women and 3.4% [n=2] who were divorced. Mean height was 164 +/- 14 cm in men and 157.5 +/- 10 cm in women. Mean BMI at the time of presentation was 22.7 in men and 22.6 in women. The most common gastrointestinal [GI] complaints in male patients were diarrhea [35%], reflux [20%], bloating [17.5%], abdominal pain [15%], vomiting [15%] and constipation [7.5%]. Female patients experienced diarrhea [49.2%], abdominal pain [31.7%], bloating [31.7%], vomiting [19%], constipation [9.5%] and reflux [7.9%]. The most common concomitant non-GI disorders among male patients were anemia [17.1%], thyroid disease [14.3%], and weight loss (14.3%); women experienced anemia [33.9%], thyroid disease [12.5%], and weight loss [7.1%]. Approximately half of the patients exhibited symptoms for more than five years prior to diagnosis and 90% were diagnosed by gastroenterologists. Of these, 43% had normal endoscopy results. The most common serologic markers were anti-TTG [69.9%], anti-EMA [27.7%]

CONCLUSION: Physicians, prior to attributing patients' symptoms to irritable bowel syndrome [IBS] should be aware that patients who present with long-term nonspecific symptoms might possibly have celiac disease. During endoscopy, the threshold for obtaining biopsies should be low

High dose versus low dose intravenous pantoprazole in bleeding peptic ulcer: a randomized clinical trial

The appropriate dose of proton pump inhibitors for treatment of patients with upper [GI] bleeding remains controversial. This study compares high-dose versus low-dose intravenous proton pump inhibitor [PPI] infusion for prevention of GI bleeding complications. A total of 166 patients with bleeding peptic ulcers underwent therapeutic endoscopy using concomitant therapy by argon plasma coagulation [APC] and diluted epinephrine injection. Patients were randomly divided into two groups: high-dose pantoprazole [80 mg bolus, 8 mg per hour] and low-dose pantoprazole [40 mg bolus, 4 mg per hour] infused for three days. Initial outcomes were rebleeding, need for surgery, hemoglobin drop more than two units, and hospitalization for more than five days. Secondary outcome included mortality rate. Overall, 166 patients [83 patients per group] enrolled in the study. The average age of patients in the high-dose group was 59.5 +/- 15.6 years and 52.3 +/- 13.3 years in the low-dose group [p=0.58]. Males comprised 69.7% of patients. In the high-dose group, the mean number of units of transfused blood was 3.3 +/- 1.71 and in the low-dose group, it was 2.82 +/- 1.73 [p=0.50]. There were 36 [43.37%] patients in the high-dose group and 40 [48.19%] in the low-dose group who were hospitalized for more than 5 days [p=0.53]. Rebleeding was observed in 27 [32.53%] patients in the high-dose group and in 21 [25.30%] in the low-dose group [p=0.30]. There were no significant differences observed in drop in hemoglobin of more than two units [p=0.15], mortality [p=0.99] and surgery [p=0.75] between the two groups. For controlling peptic ulcer bleeding, there is no difference between high dose and low dose pantoprazole infusion

[Evaluation of the efficacy of intra-nasal midazolam for sedation during upper endoscopy: a randomized clinical pilot study]

Background: upper endoscopy, as an important diagnostic and occasional therapeutic tool is invasive. Sedation of patients during the endoscopy procedure with minimal side effects could raise patient tolerability, allowing for ease and increased effectiveness of this procedure

Materials and Methods: in this study, 105 patients who were candidates for the upper endoscopy procedure were randomly divided into two groups: [A] midazolam [n=53] and [B] placebo [n=52]. Group A patients received 5 mg of midazolam dissolved in 5 cc distilled water and group B received 5 cc of distilled water, via an intra-nasal drip. After 40 to 45 minutes, the upper endoscopy was performed. During the endoscopy, patients were monitored and the endoscopy time, gag reflex stimulation, heart rate, arterial oxygen saturation [SPO2], amnesia and patient justification were recorded and compared

Results: the average age in group A was 39.3 years; for group B, it was 39.9 years. There were no statistically significant results for average endoscopy time [p=0.23], gag reflex stimulation [p=0.27], heart rate [p=0.09], SPO2 [p=0.49], amnesia [p=0.12], and patient justification [p= 0.1] between both groups

Conclusion: according to the results of this study, it seems that intra-nasal midazolam is not effective for patient sedation. This field needs additional evaluation

Evaluation of N-acetyl cysteine for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a prospective double blind randomized pilot study

Acute pancreatitis is the most common serious complication of endoscopic retrograde cholangiopancreatography [ERCP] that can occasionally be fatal. Multiple drugs have been examined for the prevention of this side effect, with generally uncertain results. This study is an effort to prevent this complication by the use of oral N-acetyl cysteine [NAC]. A total of 100 patients who were candidates for ERCP were divided randomly into two groups. In the NAC [N] group, patients received 1200 mg NAC with 150 cc water orally 2 h before ERCP. In the placebo [P] group, 150 cc water was prescribed as a placebo. We measured serum amylase and lipase levels before and 24 h after ERCP. The prevalence of pancreatitis and duration of admission in each group were determined and compared. In group N there were 5 [10%] cases of pancreatitis, whereas in group P there were 14 [28%] cases, which was significant [risk reduction ratio: 2.8; p=0.02].The average admission time was 1.16 +/- 0.55 days in group N and 1.18 +/- 0.44 days in group P, which was not significant. There were significant differences in the prevalence of acute pancreatitis between the two groups. In addition, the number of need to treat [NNT] consisted of five cases for NAC. With regards to the above results and the safety profile of NAC, it could be used as a therapeutic agent for the prevention of post-ERCP pancreatitis. We recommend that the results of this study be verified by additional clinical trials

Liver cirrhosis seen in GI clinics of Ahvaz, Iran

Liver cirrhosis is an end-stage condition fornumerous chronic liver diseases. Limited data exists on the epidemiology, natural history and complications of liver cirrhosis in Ahvaz, Iran. In a cross-sectional study we have retrospectively evaluated 165 patients from September 1, 1999 until September 1, 2008. Patients with evidence of cirrhosis of the liver seen on abdominal ultrasound were enrolled. The diagnosis was based on clinical, functional and morphological data. The etiological profile was established by determining viral and autoimmune markers, and by metabolic screening. Patients who were not confirmed to be cirrhotic were excluded from this study. All cases were studied to determine etiological factors, complications and disease prognosis. Data were recorded on a questionnaire. A total of 165 patients were studied, of which there were 114[67%] males and 51[33%] females. The mean age was 47 years. The majority of patients [70 cases [42.4%]] had evidence of HBV infection. Of HBs Ag-positive patients, 31[43.2%] were HDV Ab positive with a mean age of 41.6 years. There was no significant difference by sex among cirrhotic patients [p>0.05]. Other cases included 23 [14%] patients with autoimmune hepatitis [AIH], 15[9.1%] had HCV infection, 2[1.2%] had evidence of Wilson's disease and no etiological factors were recorded in 55 [33.3%] patients. Ascites was present in 32% of cases, splenomegaly in 29%, esophageal varices in 38%, fundal varices in 2%, peptic ulcer in 8%, acute variceal hemorrhage in 8%, various grades of hepatic encephalopathy in 1%, and hepatocellular carcinoma in6% of patients. When cirrhotic patients were grouped according to child-pugh classification, 19% were in class A, 30% were in class B, and 51% comprised class C. HBV infection was the major risk factor for cirrhosis in this study and ascites was the most common complication. There were more patients with Child-Pugh class C cirrhosis than thoseinclasses B and A. A multidisciplinary approach for the prevention and control of the increase in HBV infection must be adopted in order to inform the public about the seriousness of its complications and possible modes of transmission.

Genotypic analysis of hepatitis C virus in Khuzestan province, southwestern Iran

Hepatitis C virus [HCV] infection is responsible for considerable morbidity and mortality worldwide. The HCV genotype has a geographic distribution and an important role in clinical and histological outcomes. This study determined HCV genotypes and their related risk factors among patients from Khuzestan Province, Southwest Iran. In a cross-sectional study, 223 patients infected with HCV who referred to Ahvaz Jundishapour University Hospitals AJSUH] and Hepatitis Clinic were enrolled. Specific and nested polymerase chain reaction [PCR] and restriction fragment length polymorphisms [RFLPs] were performed to determine viral infection and genotype analysis. Liver enzymes including ALT and AST and the correlated risk factors were also determined. The HCV genotype distribution was as follows: genotype 1a [41.7%]: genotype 1b [2.7%]; genotype 2 [4.1%]; genotype 3a [31.4%]; and genotype 4 [1.8%]. There were 42 samples [18.84%] not classified into any of the known HCV subtypes. No patient was infected with more than one genotype. HIV was found in four [1.8%] cases, of which all were intravenous drug users. Univariate analysis demonstrated an independent association of intravenous drug use [IVDU] and genotypes 1a [60.7%] and 3a [30%]. Our findings suggest that genotypes 1a and 3a are the most common ones among Iranian patients with chronic hepatitis C infection in Khuzestan Province, Southwest, Iran

Incidence of Helicobacter pylori in central serous chorioretinopathy: a case control study

Helicobacter pylori infection is one of the most common infections worldwide. Central serous chorioretinopathy [CSCR] is a serous macular detachment that usually affects young people. The aetiopathogenesis of the disease is still not completely understood. Recently, an interesting association has been observed between this disease and the H. pylori infection. This study was conducted to investigate a possible association between H. pylori infection and CSCR. A prospective study was performed and we evaluated a total of 54 CSCR patients [48 males and 6 females, median age 35.7 years], and a control group of 59 patients [25 women, 34 males; mean age 42.6 +/- 11 years] who referred to gastroenterology department of Imam Hospital, Ahvaz Jundishapur University of Medical Sciences, were studied. Central serous chorioretinopathy was diagnosed on the basis of findings in ophthalmic examinations and confirmed by fluorescein angiogram. All patients underwent a [13]C-urea breath test [UBT] and serum IgG anti-bodies to H. pylori by enzyme-linked immunosorbent assay technique to detect H. pylori infection. Patients were defined as H. pylori infected if both tests were positive. The mean duration of symptoms before diagnosis was 10.5 +/- 4.5 days. Overall no statistically significant difference was found between left and right eyes, bilaterally was in 5 patients [9.2%]. The incidence of H. pylori infection was 68.5% in CSCR patients and 65% in control subjects [p=0.64]. These results indicate that the prevalence of H. pylori infection is not higher in patients with CSCR than in controls. Further large studies will be required to determine the role of H. pylori infection in patients with CSCR