Middle East Journal of Digestive Diseases
Volume:6 Issue: 1, Jan 2014

Opioids are widely used for the treatment of malignant and non-malignant pains. These medications are accompanied by adverse effects, in particular gastrointestinal symptoms known as opioid bowel dysfunction (OBD). The most common symptom of OBD is refractory constipation that is usually stable regardless of the use of laxatives. Narcotic bowel syndrome (NBS) is a subset of OBD described as ambiguous chronic pain aggravated by continual or increased opioid use for pain relief. Pathophysiology of these disorders are not definitely disentangled. Some challenging hypothesis have been posed leading to specific management in order to mitigate the adverse effects.This article is a review of the literature on the prevalence, pathophysiology and management of OBD and NBS.

Evidence indicates that insulin resistance results in poor sustained viral response (SVR) in patients with chronic hepatitis C (CHC). Metformin is an oral hypoglycemic agent which improves insulin resistance. We sought to determine if the addition of metformin to the treatment regimen could improve SVR in treatment-naïve CHC patients in a randomized, double-blind, placebo-controlled trial. We randomized 140 consecutive CHC patients to receive either metformin 500 mg three times a day or placebo in addition to pegylated interferon (PEG-IFN) and ribavirin (RBV). Only treatment-naïve subjects aged between 15 and 65 years of age were included. SVR was defined as no detectable HCV RNA six months after the end of treatment. Subjects who received at least one dose of PEG-IFN were included in the final analysis. The SVR rate in the metformin group was 75% versus 79% in controls (intention-to-treat) which was not significantly different. Also, the difference between the placebo and metformin group was not significant in subsets of different genotypes or those with homeostasis model assessment of insulin resistance (HOMA-IR) levels greater than 2 or body mass index greater than 25. The most common complaint was gastrointestinal discomfort (13% in metformin group versus 4% in controls; p=0.002) that lead to discontinuation of metformin in 8 participants. Although triple therapy with metformin, PEG-IFN and RBV is relatively well tolerated, the addition of metformin did not significantly improve viral response in CHC patients.

Worldwide, chronic liver disease is a major cause of morbidity and mortality. Causes of elevated serum alanine aminotransferase (ALT) levels vary depending on the population under study. The aim of this study is to evaluate the frequency and causes of persistently elevated ALT levels in patients of the Gastroenterology (GI) Clinics in Ghaem and Emam Reza Hospitals in Mashhad, Iran.A total of 100 consecutive patients with persistently elevated ALT levels that referred to the GI Clinics at Ghaem and Emam Reza Hospitals in 2011 were studied. Elevated levels were defined as ALT ≥40 U/L at least twice within six months. A comprehensive history that included previous surgeries, transfusion, alcohol consumption and medications was obtained. Patients underwent physical examinations, laboratory analyses and ultrasonography studies. When necessary, liver biopsies were performed. Patients'' mean age was 44.4 ± 11.83 years. Females comprised 62% of cases. Patients presented with the following conditions: non-alcoholic fatty liver disease (NAFLD, 55%), hepatitis B (17%), autoimmune hepatitis (13%), hepatitis C (4%), autoimmune hepatitis and hepatitis C (2%), overlapping autoimmune disease (2%), Wilson disease (1%), celiac disease (1%), alcoholic hepatitis (1%), primary biliary cirrhosis (PBC, 1%), primary sclerosing cholangitis (PSC, 1%), and cryptogenic (2%). NAFLD was the most common cause of persistently elevated serum ALT levels in this study.

NAFLD/NASH is a manifestation of metabolic syndrome and is associated with obesity/overweight. Not all obese/overweight individuals develop NASH. Gastro-esophageal reflux disease (GERD) is considered a gastrointestinal manifestation of the metabolic syndrome and is associated with obesity/overweight. Again not all obese/overweight individuals develop GERD. Recent data show association of dietary nitrate content and oral nitrate reductase activity (NRA) with GERD. Nitrates need to be converted to nitrite (done in human beings by nitrate reductase of oral bacteria exclusively) to be active in metabolic pathways.To assess the relation between NASH/NAFLD and oral NRA.Oral NRA was measured in individuals with NASH (compatible abdominal ultrasound and two elevated ALT/AST levels over six months) and was compared with that of those without NASH. Oral NRA was measured according to a previously reported protocol.Eleven NASH patients and twelve controls were enrolled. Mean oral NRA activity were 2.82 vs. 3.51 µg nitrite-N formed per person per minute for cases and controls respectively (p=0.46). According to our data, oral nitrite production is not different between individuals with and without NASH.

Inflammatory bowel disease (IBD) is a chronic, relapsing, inflammatory disorder of the gastrointestinal tract that includes two entities, Crohn’s disease (CD) and ulcerative colitis (UC). As with other complex diseases, both genetic susceptibility and environmental factors play role in the pathogenesis of these diseases.The tumor necrosis factor α (TNF-α) gene is located in the IBD3 region on chromosome 6p21 which is a good functional candidate for involvement in susceptibility to IBD. In addition, the promoter region of TNF-α contains various polymorphisms that have shown a significant association with IBD. In this case control study we investigated the TNF-α -857 polymorphism in 109 patients (89 UC and 16 CD) who suffered from IBD and 100 healthy age, sex and ethnicity matched adults selected from the same population, as the control group. The polymorphism was checked by amplification refractory system (ARMS) and polymerase chain reaction (PCR). Investigation of the association of TNF-α -857 gene promoter polymorphism with both types of IBD showed no significant difference in genotype and allele frequencies of this polymorphism between UC patients and controls. However, a possible association of TNF-α -857 polymorphism (p=0.03) was identified with CD. TNF-α -857 polymorphism may have a role in the development of CD in the Iranian Azeri Turkish population.

The incidence of inflammatory bowel disease (IBD) varies among different societies. The aim of this study is to determine the incidence rate of IBD in Kerman, a city in Southeast Iran. All medical records that indicated a new diagnosis of ulcerative colitis (UC) or Crohn’s disease (CD) were retrieved from the gastrointestinal endoscopy and pathology departments of 12 centers from October 2011 to September 2012.RESULTS":The incidence rate of UC in Kerman was estimated at 4.98/100,000 (95% CI: 2.44-6.94). The mean age of patients was 39.4 years and male to female ratio was 0.89:1.0. UC patients had the following prevalence: cigarette smoking (30%), appendectomy (36%) and oral contraceptive (OCP) use (78.9%). The incidence rate of CD was 0.8/100,000 (95% CI: 0.6 4-1.14). The mean age at diagnosis was 33.3 years and male to female ratio was 0.5:1.0. Cigarette smoking was reported in 33.3%, appendectomy in 66.6% and OCP useing in 75% of CD patients. Rectal and distal colitis, left side colitis and extensive colitis was seen in 20 (55.4%), 12 (33.3%) and 4 (11.1%) of patients with UC, respectively. All patients with CD had large intestinal involvement and one case (16.6%) had ileocolonic disease. Our study has shown that the incidence rate of both UC and CD in Kerman is lower than Western populations but it is the same as some Asian countries. Characteristics of disease involvement in this study are similar to other studies that have been conducted in Iran and elsewhere.

Splenic artery aneurysm (SAA) is a rare and potentially life-threatening clinical entity that carries a risk of rupture and peritoneal hemorrhage. When ruptured, it typically manifests as abdominal pain with hemodynamic instability. This is a report about a 29-year-old male admitted for evaluation of recent-onset ascites following the spontaneous resolution of a transient episode of severe epigastric and left upper quadrant pain with syncope the preceding day. Paracentesis revealed bloody fluid. Abdominal computed tomographic angiography (CTA) and magnetic resonance venography (MRV) showed a three centimeter SAA. During admission, prompt exploratory laparotomy was performed that revealed excessive intraperitoneal hemorrhage due to a ruptured SAA. The pathology report confirmed that the SAA had developed secondary to atherosclerosis. Careful history taking together with appropriate imaging tests and emergent surgical intervention led to a timely diagnosis and the patient''s survival.

Autoimmune pancreatitis is a fibro-inflammatory form of chronic pancreatitis. It is diagnosed by the combination of imaging studies such as a CT scan and pancreatography, laboratory analyses that include IgG4 and/or autoantibodies, histopathological evaluations and positive response to corticosteroid therapy. We report the case of a 41-year-old female with a history of jaundice and increasing abdominal pain for two weeks prior to her clinic visit. Laboratory results were significant for an increase in alkaline phosphatase (ALP) and erythrocyte sedimentation rate (ESR). Magnetic resonance cholangiopancreatography (MRCP) confirmed areas of stenosis and dilatation in the pancreatic duct and in the intra- and extra-hepatic bile ducts similar to primary sclerosant cholangitis. Laboratory analyses showed increased levels of IgG4 with the presence of antinuclear antibodies.