Middle East Journal of Digestive Diseases最新文献

Pancreatic cancer (PC) is a lethal cancer with poor prognoses. Identifying and characterizing pancreatic cystic lesions (PCLs) in the early detection and follow-up plans is thought to help detect pancreatic malignancy. Besides, the molecular features of PCLs are thought to unravel potentials for targeted therapies. We present a narrative review of the existing literature on the role of PCLs in the early detection, risk stratification, and medical management of PC. High-grade intraductal papillary mucinous neoplasms (IPMN) and pancreatic intraepithelial neoplasia (PanIN) stage III are high-risk lesions for developing PC. These lesions often require thorough histomolecular characterization using endoscopic ultrasound (EUS), before a surgical decision is made. EUS is also useful in the risk assessment of PCLs with tentative plans-for instance, in branch-duct IPMNs (BD-IPMN)- where the final decision might change. Besides the operative decisions, recent improvements in the application of targeted therapies are expected to improve survival measures. Knowledge of molecular features has helped develop targeted therapies. In summary, the histomolecular characterization of PCLs is helpful in optimizing management plans in PC. Further improvements are still needed for the broad application of this knowledge in the clinical setting.

Background: The possibility of pelvic floor dysfunction (PFD) occurrence seems to be higher in patients with inflammatory bowel disease (IBD) due to the presence of functional gastrointestinal disorders in these patients. Hence, this study aimed to evaluate the association of ulcerative colitis (UC) in women with PFD and its comparison with the healthy (without IBD) population.

Methods: The present study was conducted on 150 women with UC and 150 without-IBD individuals. Pelvic Floor Distress Inventory (PFDI-20) was used to evaluate the pelvic floor function.

Results: The results of this study revealed that UC had a significant role in increasing not only the PFD score (Beta=3.04; P<0.001) but also the score of each sub-scale of Pelvic Organ Prolapse Distress Inventory (POPDI) (Beta=6.61; P<0.001), Colo-Rectal-Anal Distress Inventory (CRADI) (Beta=9.37; P<0.001), and Urinary Distress Inventory (UDI) (Beta=5.56; P=0.015). In addition, aging, increased body mass index (BMI) and menopause had significant role in increasing POPDI, UDI, and PFDI scores, respectively (P<0.05).

Conclusion: The percentage of PFD in women with UC was significantly higher than its percentage in women without IBD. This dysfunction was more visible in the two sub-scales of POPDI and CRADI. In addition to having UC, aging, BMI, and menopause played a significant role in increasing PFD.

Background: Fissure-in-Ano is a common condition of the anorectal region. Most of the time, it is managed non-surgically. There are various drugs used for the treatment of anal fissures. Calcium channel blockers are one of them that reduce the tone of sphincter muscles. The present study compares the efficacy of oral diltiazem and topical 2% diltiazem ointment in patients with chronic anal fissures.

Methods: Patients were randomized into two groups. Group A (n=25) received treatment in the form of oral diltiazem, while group B (n=25) received treatment in the form of 2% (weight/volume) diltiazem ointment for local application in addition to other conservative methods like sitz bath and stool softeners. Outcomes in the form of success of treatment and complications were assessed. Statistical analysis was done using MedCalc software version 14.0. P value of<0.05 was considered significant.

Results: The mean age of patients was 32.00±10.67 years in group A and 30.64±9.53 years in group B. Pain relief was significantly better in group B than in group A at the end of the first week (P=0.00018), but at the end of 6th week, no significant difference was observed. Fissure healing was more significant in group B than in group A after 6 weeks (P=0.0152).

Conclusion: Local diltiazem ointment is a better option than oral diltiazem for anal fissures with respect to better outcomes and lesser complications.

Background: Pancreatic duct (PD) dilation could be presented in both benign and malignant diseases. Endoscopic ultrasonography (EUS) is a sensitive modality that provides both structural assessment and tissue sampling. This study aims to explore the importance of PD dilation as a potential indicator related to various pancreatobiliary pathologies identified via EUS.

Methods: Among 3109 subjects who underwent EUS, 599 had evidence of dilated PD and met the inclusion criteria of this retrospective study. Also, the patients underwent EUS fine needle aspiration (EUS-FNA) to evaluate the etiology when required. All data were extracted from patients' medical records to perform statistical analysis.

Results: The study sample revealed 64% being male with a median age was 65-years. Pancreatic adenocarcinoma was the most common etiology diagnosed in 236 patients (39.4%), followed by sphincter of Oddi dysfunction (SOD) in 13% of subjects. Ampullary carcinoma, common bile duct stone, and cholangiocarcinoma were found at 9.5%, 8.8%, and 6.8%, respectively. Abdominal pain was the most common symptom seen in 440 (73.4%) patients. Opium consumption was reported in 170 (28.4%) subjects. Opium consumption was significantly more prevalent in patients with SOD (P<0.05).

Conclusion: We suggest that PD dilation could be associated with a wide range of pancreaticobiliary pathologies, especially pancreatic neoplasms. In this regard, PD dilation should be considered as a crucial indicator of pancreatic neoplasm despite it may be associated with no clear etiologies.

Background: Iatrogenic bile duct injury (BDI) is one of the most common complications that challenge surgeons performing laparoscopic cholecystectomy (LC). As the number of LC surgeries increases, a pattern of BDI is emerging, but little is known about this matter. The purpose of this study was to assess the pattern of post-LC BDIs directed in a referral center in Iran.

Methods: Post-BDI patients referred to a hepatobiliary center were studied. Demographic data, clinical status, diagnostic examinations, referral time, post-referral management, and morbidity were analyzed.

Results: Nine out of 68 patients had Charcot's cholangitis triad featuring right upper quadrant abdominal pain, fever, and icter. Fever, icter, and itching were the most frequent symptoms. Increased bilirubin, leukocytosis, and abnormal liver function test (LFT) were the most common laboratory abnormalities. 30 patients experienced hepatic artery injury. Out of them, six patients experienced hepatectomy due to hepatic ischemia. Two patients were re-admitted and re-operated, and four patients died.

Conclusion: Early and correct treatment by a hepatobiliary surgeon experienced in the management of these types of injuries prevents further complications in patients suffering from iatrogenic BDI. Postoperative complications of bile duct repair, such as anastomosis stricture, are possible; thus, patients need long-term and thorough postoperative observation.

Background: Helicobacter pylori, the most prevalent infection in the world, has great importance due to being related to peptic ulcer disease, gastric metaplasia, dysplasia, and even gastric adenocarcinoma or mucosa-associated lymphoid tissue (MALT) lymphoma. The standard H. pylori eradication regimen is based on antibiotic susceptibility testing. If susceptibility testing is not available, a standard treatment regimen will be recommended based on records of H. pylori resistance rates to antibiotics in a region or locally proven highly effective regimens (equal to or higher than 90% eradication rate). The aim of this review was to define suitable recommendations for local treatment in different cities of Iran.

Methods: This review article consists of randomized controlled trials related to H. pylori eradication in Iran. Data including the kind of therapy, number of patients and per-protocol H. pylori eradication rates were recorded in data gathering forms. Data search was conducted in PubMed and Google Scholar databases from 2018 to December 2023.

Results: According to our review of Iranian articles regarding first-line H. pylori eradication regimens, these treatment protocols could be recommended: Bismuth-clarithromycin quadruple therapy in Ardabil, bismuth-clarithromycin quadruple therapy with probiotics in Birjand, standard triple therapy in Ilam, bismuth quadruple therapy or bismuth triple therapy or concomitant regimen in Sari, sequential therapy in Tehran and bismuth quadruple therapy in Yazd. These regimes can be extended to other regions that have a similar situation. According to the reports of Iranian researchers, a quinolone-containing regimen (levofloxacin preferred) is recommended for second-line eradication therapy.

Conclusion: Various H. pylori eradication regimens can be used as first-line therapy; however, choices for second-line therapy are limited. We recommend the quinolone-containing regimens as the preferred second-line therapy.

Gastric necrosis is a very rare surgical emergency in a previously healthy child. A 13-year-old boy with abdominal pain and coffee-ground vomiting was admitted to the emergency department. Physical examination revealed signs of peritonitis and septic shock. The patient underwent a laparotomy. Gastric necrosis and discoloration of the lower esophagus and duodenum due to ischemia were present. Distention of gastric and duodenum was also seen. Total gastrectomy and Roux-en-Y esophagojejunostomy were done. The patient underwent a chest computed tomography (CT), and patchy ground-glass opacity was observed in both lungs. Consolidation was seen in the lower lobe of the lung. The polymerase chain reaction (PCR) for coronavirus was tested two times. The first time was negative, and the second time was positive. The patient was discharged in good condition. During the follow-up period, severe anastomotic strictures occurred. In our case, gastric necrosis and positive coronavirus were reported.

Budd-Chiari syndrome (BCS) is characterized by hepatic venous outflow tract obstruction and is commonly associated with an underlying hypercoagulable state. Systemic amyloidosis is a disorder characterized by systemic deposition of misfolded proteins leading to end organ damage. Amyloidosis is commonly associated with coagulation abnormalities, mainly leading to increased bleeding diathesis. Here, we report a case of amyloid light chain (AL) amyloidosis presenting as BCS. A 40-year-old man presented with abdominal distension along with anorexia and weight loss. On evaluation, he had severe hypoalbuminemia, raised alkaline phosphatase, and non-visualization of hepatic veins on abdominal imaging. Further evaluation confirmed the diagnosis of AL amyloidosis with renal, cardiac, and hepatic involvement. AL amyloidosis rarely can present with BCS. A high index of suspicion is needed as symptoms can be variable and non-specific.

Background: Diarrhea-dominant irritable bowel syndrome (IBS-D) is a deliberating and chronic condition that can impair social activities. Determining proper medication with satisfactory outcomes has been a challenge. The 5-hydroxytryptamine 3 receptor antagonist (5-HT3 RA) drugs have demonstrated favorable outcomes on IBS-D in the last 3 decades. Ondansetron, also a 5-HT₃ RA is known as an antiemetic. Our aim was to evaluate the efficacy of ondansetron in IBS-D.

Methods: In this single-center, double-blind, randomized controlled trial, patients with IBS-D were recruited. Patients were randomized on a 1:1 ratio and assigned into two groups: imipramine 25 mg/daily plus ondansetron 4 mg/3 times per day and imipramine 25 mg/daily plus placebo. The primary endpoint was the frequency of diarrhea per day after 8 weeks of treatment. The secondary endpoints consisted of changes in the frequency of defecation urgency per day, the number of days with gastrointestinal pain and bloating, and the patients' overall satisfaction regarding bowel habits after 8 weeks of the treatment.

Results: Data from 98 patients were analyzed. Ondansetron, compared to placebo, improved the primary outcome, and the stool consistency was increased significantly (3.29±1.19 vs 4.55±1.17, P<0.001). Moreover, the response rate for the diarrhea frequency was significantly higher in the ondansetron group compared to the placebo (77.5% vs 34.7%, P<0.001). In the ondansetron group, fewer urgencies were experienced, and pain severity and feeling of bloating declined as well (P<0.01).

Conclusion: Ondansetron can mitigate almost all IBS-D-related symptoms, which may indicate it as a drug of choice; however, further evidence is required to ascertain its safety.

Gastric bezoar is a very rare clinical condition and hard to treat. Phytobezoars are one of the most common types of bezoars, which happens with the consumption of indigestible fibers. In this report, we presented an elderly man with gastric phytobezoar who presented with peptic ulcer and was treated successfully with proton pump inhibitor (PPI) and Coca-Cola. Surveillance endoscopy showed a completely healed ulcer. It was shown that cautious use of Coca-Cola can be helpful and safe in treating concomitant phytobezoar and gastric ulcers. To the best of our knowledge, this is the first report of phytobezoar from Iran, which was treated with cola.