Portal vein thrombosis as extraintestinal complications of Crohn's disease: a case report and review of literature.

INTRODUCTION: Thrombotic events are more than twice as common in inflammatory bowel disease patients as in the general population. We report an interesting and rare case of portal vein thrombosis as a venous thromboembolic event in the context of extraintestinal manifestations of Crohn's disease. We also conducted a literature review on portal vein thrombosis associated with inflammatory bowel disease, with the following concepts: inflammatory bowel diseases, ulcerative colitis, Crohn's disease, portal vein, and thrombosis. CASE PRESENTATION: A 24-year-old Syrian female with active chronic Crohn's disease was diagnosed 11 years ago and classified as A1L3B1P according to the Montreal classification. She had no prior surgical history. Her previous medications included azathioprine and prednisolone. Her Crohn's disease activity index was 390 points. Gastroduodenoscopy revealed grade I esophageal varices, a complication of portal hypertension. Meanwhile, a colonoscopy revealed several deep ulcers in the sigmoid, rectum, and descending colon. An investigation of portal vein hypertension revealed portal vein thrombosis. We used corticosteroids to induce remission, followed by tapering; additionally she received ustekinumab to induce and maintain remission. She began on low-molecular-weight heparin for 1 week, warfarin for 3 months, and then apixaban, a novel oral anticoagulant, after excluding antiphospholipid syndrome. Primary prophylaxis for esophageal varices was not required. After 1 year, she achieved clinical, biochemical, and endoscopic remission. Despite 1 year of treatment, a computed tomography scan revealed no improvement in portal vein recanalization. CONCLUSION: Portal vein thrombosis is a rare and poorly defined complication of inflammatory bowel disease. It is usually exacerbated by inflammatory bowel disease. The symptoms are nonspecific and may mimic a flare-up of inflammatory bowel disease, making the diagnosis difficult. Portal vein Doppler ultrasound for hospital-admitted inflammatory bowel disease patients may contribute to the diagnosis and management of this complication.

Efficacy of a 2-week therapy with levofloxacin concomitant versus a levofloxacin sequential regimen for Helicobacter pylori infection in the Syrian population: a study protocol for randomized controlled trial.

BACKGROUND: Treating Helicobacter pylori is becoming increasingly difficult with the development of bacterial resistance to many established treatment regimens. As a result, researchers are constantly looking for novel and effective treatments. This trial aims to establish the efficacy of levofloxacin-based sequential treatment regimen and concomitant levofloxacin-based regimen as empirical first-line therapy in the Syrian population. METHOD: This is an open-label, prospective, single-center, parallel, active-controlled, superiority, randomized clinical trial. The recruitment will target Helicobacter pylori-positive males and females between the ages of 18 and 65 to evaluate the efficacy of empirical first-line therapy in the Syrian population. We are planning to recruit up to 300 patients which is twice the required sample size. One hundred fifty individuals will be randomly assigned to undergo either a sequential levofloxacin-based treatment regimen or a concomitant levofloxacin-based regimen. High-dose dual therapy (proton-pump inhibitor and amoxicillin) will be the rescue therapy in the event of first-line failure. The first-line eradication rate in both groups is the primary outcome, and one of the secondary outcomes is the overall eradication rate of high-dose dual therapy in the event of first-line treatment protocol failure. Intention-to-treat analysis and per-protocol analysis will be used to evaluate the eradication rates of Helicobacter pylori for first-line treatment protocols. DISCUSSION: For the first time in the Syrian population, this randomized controlled trial will provide objective and accurate evidence about the efficacy of a sequential levofloxacin-based treatment regimen. TRIAL REGISTRATION: ClinicalTrials.gov NCT06065267 . Registered on October 3, 2023. Prospective registered. Enrollment of the first participant has not started yet.

Therapeutic effects of biological treatments on AA amyloidosis associated with inflammatory bowel disease: a case report and literature review.

AA amyloidosis is a rare and significant complication of long-term inflammation that can be caused by a variety of disorders, including inflammatory bowel disease, and is linked to an increased risk of morbidity and mortality. To date, there has been no effective direct treatment, and treatment aims at treating the underlying condition with potent immunosuppression to limit inflammatory activity and, as a result, switch off amyloidogenesis. Theoretically, biological treatment can control AA amyloidosis by inducing and maintaining inflammatory bowel disease remission and inhibiting the synthesis of Serum Amyloid A, which is an acute phase reactant and precursor protein of AA amyloidosis that accumulates in the organs. We report the first case of ustekinumab's therapeutic effect after infliximab's loss of response in AA amyloidosis associated with Crohn's disease. We also conducted a literature review of the therapeutic effect of biological treatment on AA amyloidosis.

Pyoperitoneum as a consequence of perinephric abscess spontaneous rupture. A case report.

Intra-abdominal infections are a common cause of severe sepsis and have a significantly high morbidity and mortality rate. Patients continue to present to hospitals with unacceptable delays in diagnosis or management, resulting in sepsis and organ failure, which lower their survival chances. We reported a rare case of a 64-year-old Syrian woman with a spontaneous rupture of a perinephric abscess that resulted in intra-abdominal infection and ascites, which led to sepsis and multiple organ failure despite resuscitation and antibiotic treatment according to guidelines. Although the recommendations for patients with intra-abdominal infection and hemodynamic instability differ, there is an agreement that surgery should be considered early when other interventional approaches have failed. Rupture of the perinephric abscess rarely produces intra-abdominal infection and ascites; effective care requires early and appropriate infection source identification. To avoid delays, doctors need to use academic methods in developing diagnoses and management.

Mortality and risk factors associated with peptic ulcer bleeding among adult inpatients of Damascus Hospital, Syria: A cross-sectional study.

Peptic ulcer bleeding is associated with significant morbidity and mortality, while monitoring mortality is extremely beneficial to public health, and the latest estimates date back to 2010 for the Syrian population. This study aims to estimate the in-hospital mortality rate and risk factors associated with peptic ulcer bleeding among adult inpatients at Damascus Hospital, Syria. A cross-sectional study with systematic random sampling. Sample size (n) was calculated using the proportional equation: [n = Z2P (1 - P)/d2], with the following hypothesis: Z = 1.96 for the 95% confidence level, P = .253 for mortality in patients hospitalized with complicated peptic ulcers, a margin of error (d) = 0.05, 290 charts were reviewed, and the Chi-square test (χ2 test) was used for categorical variables, and the t test for continuous data. We reported the odds ratio in addition to mean and standard deviation with a 95% confidence. A P value less than .05 was considered statistically significant. Data were analyzed using a statistical package for the social sciences (SPSS). The mortality rate was 3.4%, and the mean age was 61.76 ±â€…16.02 years. The most frequent comorbidities were hypertension, diabetes mellitus, and ischemic heart disease. The most commonly used medications were NSAIDs, aspirin, and clopidogrel. 74 patients (25.52%) were using aspirin with no documented indication P < .01, odds ratio = 6.541, 95% CI [2.612-11.844]. There were 162 (56%) Smokers. Six patients (2.1%) suffered from recurrent bleeding, and 13 (4.5%) needed surgery. Raising awareness about the risks of using non-steroidal anti-inflammatory drugs may reduce the occurrence of peptic ulcers and, as a result, peptic ulcer complications. Larger, nationwide studies are needed to estimate the real mortality rate in complicated peptic ulcer patients in Syria. There is a lack of some critical data in the patients' charts, which necessitates action to correct.

Ustekinumab for steroid-refractory pancolitis in a biologically naive child: A case report and literature review.

Ustekinumab is not recommended for the treatment of children with inflammatory bowel disease, but its off-label use is increasing despite a lack of pediatric pharmacokinetic data. The purpose of this review is to evaluate the therapeutic effects of Ustekinumab on children with inflammatory bowel disease and to recommend the best treatment regimen. Ustekinumab was the first biological treatment for a 10-year-old Syrian boy with steroid-refractory pancolitis who weighed 34 kg. A 260 mg/kg (~6 mg/kg) intravenous dose was followed by 90 mg of subcutaneous Ustekinumab at week 8 (induction). The patient was supposed to receive the first maintenance dose after twelve weeks, but after ten weeks, he developed acute severe ulcerative colitis which was managed according to treatment guidelines, except receiving 90 mg of subcutaneous Ustekinumab when he was discharged. The maintenance dose of 90 mg subcutaneous Ustekinumab was intensified to every 8 weeks. Throughout the treatment period, he achieved and maintained clinical remission. In pediatric inflammatory bowel disease, a dose of intravenous ~6 mg/kg of Ustekinumab is a common induction regimen, while children weighing < 40 kg may require a dose of 9 mg/kg. For maintenance, children may require 90 mg of subcutaneous Ustekinumab every 8 weeks. The outcome of this case report is interesting with improved clinical remission and highlighting the expansion of clinical trials on Ustekinumab for children.

Allgrove syndrome: a case report.

Allgrove syndrome (AS), or Triple-A syndrome, is a multi-system disorder characterized by alacrima (a decrease or absence of tear production), adrenal insufficiency and achalasia (absence of esophageal muscle peristalsis and failure to relax the lower esophageal sphincter). This syndrome may affect the autonomic nervous system, in which case it is called a 4A syndrome. It is a rare autosomal recessive inheritance, and early identification is difficult due to the rarity and wide phenotypic variation even among members of the same family. Endocrinologists, gastroenterologists, ophthalmologists, neurologists and surgeons are needed to coordinate care for these patients. We describe a case of AS that took several years to complete the diagnosis. She was diagnosed with alacrima at the age of 1-year-old, adrenal insufficiency at the age of 9 and achalasia at the age of 16. This case demonstrates the difficulty and delay in the diagnosis of AS.

Ulcerative colitis-associated bronchiectasis: A rare extraintestinal manifestation of inflammatory bowel disease: A case report.

RATIONALE: Inflammatory bowel disease patients may suffer from extraintestinal manifestations. Although muscles, joints, and skin are the most commonly affected, respiratory involvement is more prevalent than previously believed, and the majority of these patients have no symptoms. Although the large airways are the most frequently affected, the small airways, lung parenchyma, and pulmonary vasculature may also be affected. PATIENT CONCERNS: A 24-year-old nonsmoking Syrian female was referred to the pulmonary medicine clinic in December 2020 due to a chronic cough. Her cough had been present for the last year, it was described as scratchy, and produced small amounts of mucoid sputum occasionally. She denied any related wheeze, hemoptysis, weight loss, or night sweats. Multiple courses of antibiotics were prescribed by many doctors, also previous chest radiographs were reported as normal. She was diagnosed with ulcerative colitis in 2012 after presentation with abdominal pain and per rectal bleeding. The diagnosis was confirmed via colonoscopy and colon biopsies, with no prior surgery. Her past medications included prednisone, mesalamine, azathioprine, and infliximab. Tests, including complete blood count, C-reactive protein (CRP), fecal calprotectin, and chest X-ray, were normal. DIAGNOSIS: Ulcerative colitis-associated bronchiectasis was established through history and clinical examination beside pulmonary function test, which revealed a mild obstructive pattern, and a chest computed tomography follow-up that revealed bilateral bronchiectasis. INTERVENTIONS: Bronchiectasis was treated with inhaled oral steroids and sputum expectoration while she continued mesalamine and azathioprine for ulcerative colitis. OUTCOME: Cough improvement and sustained ulcerative colitis remission. CONCLUSIONS: Identification of inflammatory bowel disease pulmonary exacerbation is probably poor, as pulmonary symptoms might emerge at any moment during the illness, and are most commonly diagnosed later in life and with the disassociation of inflammatory bowel disease activity. Pulmonologists should be involved in the care of inflammatory bowel disease patients who developed lung symptoms.

Advanced diffuse gastric adenocarcinoma in young Syrian woman. A case report.

Introduction: Gastric cancer is a deadly disease with vague early symptoms. Its occurrence and prognosis in young patients have demonstrated significant variation and delay in detection, which is the most critical variable in disease prognosis. Case presentation: We report a rare case of a 27-year-old Syrian female with metastasis diffuse gastric cancer with delayed diagnosis and poor prognosis without relevant history. She presented with two years of fatigue, loss of appetite, and postprandial abdominal pain, which has worsened over the past two months, vomiting, weight loss, and ascites. Gastroduodenoscopy showed superficial ulcers, with a positive Helicobacter Pylori infection. The computerized tomography (CT) scan revealed extensive thickening of the stomach, ascites, and Sister Mary Joseph nodule. The nodule tissue morphology coupled with immunostaining showed a poorly differentiated adenocarcinoma metastatic from the stomach. She was referred to a specialized oncology hospital for follow-up and palliative treatment. Clinical discussion: Gastric adenocarcinoma affects people in their fifties and sixties, and rarely in their twenties. Risk factors include diet, smoking, alcoholism, long-term use of proton pump inhibitors, Helicobacter pylori infection, pernicious anemia, and a genetic and family history of malignancies. Diagnosis at an early stage is essential in predicting prognosis. The diffuse gastric cancer spreads along the wall rather than into the lumen. The challenge is to detect tumors. Conclusion: Gastric diffuse cancer screening and surveillance programs have yet to be defined. It is still unclear who should be screened when the screening should begin, and how the screening should take place.

Subcutaneous golimumab to treat a biological naïve chronically active ulcerative colitis child. A case report.

Introduction: Ulcerative colitis is an immune-mediated disease that carries challenges in pediatrics since it's frequently severe and extensive. Current pediatric ulcerative colitis guidelines offer a weak recommendation regarding the usage and the dosage of golimumab in low-weight children. We present a case of an off-label, unrecommended dose of subcutaneous golimumab to treat low-weight chronic active ulcerative colitis child. Case presentation: A 10-year-old Syrian girl, anti-TNF naïve, chronically active ulcerative colitis was weighs 25 kg, standing 142 cm tall, body surface area (BSA) of 0.993 m2, past medications included oral prednisone and mesalamine, no prior surgery. We used golimumab 200 mg, 100 mg at weeks 0, 2 as induction, then 50 mg every four weeks for about two years. Clinical discussion: The recommendation regarding the use of subcutaneous golimumab in pediatrics is weak since is based on an open-label pharmacokinetics cohort. It is available in 100 mg/1 ml, 50 mg/0.5 ml as a smart SmartJect, or in 45 mg/0.45 ml in VarioJect which provides golimumab from 10 mg to 45 mg in increments of 5 mg/0.05 ml. Golimumab Varioject is in short supply, and unavailable in several regions including Syria. The recommended golimumab maintenance dose always requires two injectors, which adds another burden. Conclusion: This case demonstrated that golimumab 200 mg, 100 mg at week 0, 2 as an induction then 50 mg every four weeks was efficacious and safe in<45 kg children, there were no side effects or adverse events during two years therapy period.

SARS-CoV-2 (COVID-19) pneumonia patient treated with two doses of infliximab within 2 weeks for acute severe ulcerative colitis: A case report.

RATIONALE: The ongoing coronavirus pandemic has caused severe acute respiratory syndrome, posing a significant challenge for patients receiving immunotherapy for immune-mediated inflammatory diseases. As of January 2022, immunosuppressants such as tumor necrosis factor inhibitors (anti-TNFα) and azathioprine are inadvisable for an infectious disease caused by the SARS-CoV-2 virus (COVID-19). We continued infliximab as a second induction dose nine days after the onset of COVID-19 symptoms in a patient with acute severe ulcerative colitis. PATIENT CONCERNS: We report the case of a 34-year-old male with 6 to 8 times bloody diarrhea, fever, and cramping abdominal pain. Ulcerative colitis was diagnosed 6 months earlier and treated with mesalamine 80 mg/kg/day and azathioprine 2.5 mg/kg/day. The patient had never undergone surgery before. Sigmoidoscopy revealed multiple ulcerations and spontaneous bleeding, and the colon samples tested negative for cytomegalovirus and Clostridium difficile. However, intravenous corticosteroids did not induce remission. A nasopharyngeal swab tested positive for SARS-CoV-2. DIAGNOSIS: Acute severe ulcerative colitis and SARS-CoV-2 (COVID-19) pneumonia. INTERVENTIONS: The second loading dose of infliximab was administered nine days after the diagnosis of COVID-19. OUTCOME: The patient completed infliximab induction at a dose of 5 mg/kg at weeks 0, 2, and 6, with no complications. LESSONS: It is unclear whether anti-TNF-α treatment improves or deteriorates COVID-19 patient outcomes, and this case demonstrates that infliximab can be used safely. Current guidelines make a weak recommendation to avoid using anti-TNFα agents in the presence of acute COVID-19 infection. There is an urgent need for research on biologics therapy.

Subcutaneous golimumab induced and maintained clinical response in a child with a biological-experienced steroid-refractory flare of ulcerative colitis: A case report.

INTRODUCTION: Golimumab is a fully human antitumor necrosis monoclonal antibody that can be administered by either subcutaneous injection or intravenous infusion. Golimumab is approved for the treatment of the adults with rheumatic diseases, and ulcerative colitis, Whereas in children, golimumab is indicated only for the treatment of active polyarticular juvenile idiopathic arthritis. We have written on the off-label use of subcutaneous golimumab, which helped to induce and maintain remission on a low-weight biologically experienced child with steroid-refractory ulcerative colitis flare. PATIENT CONCERNS: A 13-year-old pancolitis Syrian boy presented with abdominal pain and six to seven times bloody diarrhea. The child had treated with mesalamine 80 mg/kg/day, azathioprine 2.5 mg/kg/day, infliximab with an induction dose of 5 mg/kg at weeks 0, 2, and 6 followed by 5 mg/kg every 8 weeks. Infliximab did not maintain remission as the patient suffered from two flares that required hospital admission, intravenous corticosteroids, and infliximab escalation. Initial tests disclosed leukocytosis, anemia, hypoalbuminemia, an elevation in C-reactive protein and fecal calprotectin. All Stool studies were negative including routine stool cultures, Clostridium difficile toxin, Escherichia coli O157:H7, Cryptosporidium, and microscopy for ova and parasites. A sigmoidoscopy revealed multiple large ulcerations and spontaneous bleeding, colon biopsies were negative for Clostridium difficile and Cytomegalovirus. Cyclosporine, tacrolimus, and adalimumab were unavailable in Syria. Child's parents opposed colectomy as a treatment option. DIAGNOSIS: Ulcerative colitis flare. INTERVENTIONS: A subcutaneous golimumab with a loading dose of 200 mg at week 0, followed by 100 mg at week 2, then 50 mg every 4 weeks. OUTCOMES: The patient achieved clinical remission by week sixth and maintained the remission for the next 90 weeks. At the time of last evaluation, tests, including C-reactive protein and fecal calprotectin, were within normal limits, complete colonoscopy revealed erythema, edema, mucosal friability, loss of vascular patterns, and pseudo-polyps. The Pediatric Ulcerative Colitis Activity Index and Mayo scores were 5 and 2 points, respectively. No adverse events were documented. CONCLUSION: Golimumab has shown potential efficacy and safety in the treatment of ulcerative colitis in children which may indicate a significant future role for subcutaneous golimumab in pediatrics ulcerative colitis.

Efficacy of two-week therapy with doxycycline-based quadruple regimen versus levofloxacin concomitant regimen for helicobacter pylori infection: a prospective single-center randomized controlled trial.

BACKGROUND: Antibiotic-resistance reduces the efficacy of conventional triple therapy for Helicobacter Pylori infections worldwide, which necessitates using various treatment protocols. We used two protocols, doxycycline-based quadruple regimen and concomitant levofloxacin regimen. The aim was to assess the effectiveness of doxycycline-based quadruple regimen for treating Helicobacter Pylori infections compared with levofloxacin concomitant regimen as empirical first-line therapy based on intention-to-treat (ITT) and per-protocol analyses (PPA) in Syrian population. SETTINGS AND DESIGN: An open-label, randomised, parallel, superiority clinical trial. METHODS: We randomly assigned 78 naïve patients who tested positive for Helicobacter Pylori gastric infection, with a 1:1 ratio to (D-group) which received (bismuth subsalicylate 524 mg four times daily, doxycycline 100 mg, tinidazole 500 mg, and esomeprazole 20 mg, each twice per day for 2 weeks), or (L-group) which received (levofloxacin 500 mg daily, tinidazole 500 mg, amoxicillin 1000 mg, and esomeprazole 20 mg each twice per day for two weeks). We confirmed Helicobacter Pylori eradication by stool antigen test 8 weeks after completing the treatment. RESULTS: Thirty-nine patients were allocated in each group. In the D-group, 38 patients completed the follow-up, 30 patients were cured. While in the L-group, 39 completed the follow-up, 32patients were cured. According to ITT, the eradication rates were 76.92%, and 82.05%, for the D-group and L-group respectively. Odds ratio with 95% confidence interval was 1.371 [0.454-4.146]. According to PPA, the eradication rates were 78.9%, and 82.05% for the D-group and L-group respectively. The odds ratio with 95% confidence interval was 1.219 [0.394-3.774]. We didn't report serious adverse effects. CONCLUSIONS: Levofloxacin concomitant therapy wasn't superior to doxycycline based quadruple therapy. Further researches are required to identify the optimal first-line treatment for Helicobacter-Pylori Infection in the Syrian population. TRIAL REGISTRATION: We registered this study as a standard randomized clinical trial ( Clinicaltrial.gov , identifier- NCT04348786 , date:29-January-2020).

Pilot study: Comparing efficacy of 14-day triple therapy Clarithromycin versus levofloxacin on eradication of Helicobacter pylori infection in Syrian population single-center experience.

CONTEXT: Goals: To compare the efficacy of standard triple therapy with clarithromycin versus triple therapy with levofloxacin for treatment of Helicobacter pylori-positive infection in a referral hospital in Damascus, Syria. DESIGN: pilot prospective open-label randomized controlled trial. SUBJECTS AND METHODS: Eighty treatment-naive patients who tested positive for H. pylori gastric infection were randomly assigned to one of two treatment groups with randomization ratio of 50/50. Group (A) was treated with clarithromycin (500 mg), amoxicillin (1000 mg), and esomeprazole (20 mg), each twice/day for 14 days, while Group (B) was treated with levofloxacin (500 mg), amoxicillin (1000 mg), and esomeprazole (20 mg), each twice/day for 14 days.[1] After 6 weeks of treatment, all patients underwent endoscopy and biopsy to evaluate H. pylori infection eradication. RESULTS: Forty patients were allocated in each group; 37 patients completed the follow-up in each group. Thirteen patients in Group (A) were cured, with an eradication rate of 35.1% according to per-protocol analysis (PPA) and 32.5% according to intention-to-treat analysis (ITT), while in Group (B), 11 patients were cured, with an eradication rate of 29.7% according to PPA and 27.5% according to ITT with P = 0.80. No serious adverse events reported in both the groups. CONCLUSIONS: Clarithromycin is slightly better than levofloxacin in treatment of H. pylori gastric infection, but both regimens show low effectiveness with suboptimal eradication rates in our selected population.