Govaresh
Volume:23 Issue: 4, 2019

Non-alcoholic fatty liver disease (NAFLD) is a common cause of chronic liver disease worldwide. Recent studies have shown that NAFLD occurs in both sexes, at any age, and in any economic situation. In Iran, the prevalence of NAFLD has been reported between 2.09% and 2.9%. The most common cause of the disease is insulin resistance, along with obesity and cardiovascular disease. The true incidence and prevalence of NAFLD can be difficult to determine due to the variability in the definition of the disease. Clinical symptoms of fatty liver disease are often unreliable and non-specific, and diagnostic methods include biochemical markers of radiological imaging accompanied by liver biopsy. The most commonly used treatments are diet, exercise, and pharmacological and surgical treatment of the liver. In this article, after the introduction of the disease and symptoms, epidemiology, etiology, complications, laboratory findings, differential diagnoses, treatment, and follow-up are described. Diagnostic methods of this disease include laboratory tests, biomarkers, imaging studies such as ultrasonography, computed tomography, magnetic resonance imaging, and fibroscopy, and biopsy sampling. Interactions such as lifestyle changes, weight loss, insulin resistance management, lipid lowering factors, decrease weight, drugs, surgery, and liver transplantation are effective treatments. Management of NAFLD and early and correct diagnosis and treatment of this disease can reduce the mortality and morbidity of the disease.

Helicobacter pylori (H. pylori) as a pathogenic organism is colonized in the gastric microniche of 50% of the world's population. Although research on this bacterium has been taking place over the last few decades, the best strategies ending in its eradication remain unclear. The main cause of H. pylori treatment failure is a rapid increase in antibiotic resistance. A systematic review of the literature on H. pylori antibiotic resistance in Iran was performed within the time span of 1997 to 2017. Data obtained from various studies were collected as follows, 1) year of research 2) number of the strains of H. pylori tested, 3) study place, 4) resistance of H. pylori to various antibiotics as a percentage and 5) methods used for evaluation of antibiotic resistance. In total, 36 studies have been conducted on antibiotic resistance of H. pylori strains isolated from different parts of Iran. The mean antibiotic resistance among H. pylori strains to various antibiotics were as follows: metronidazole (59.95%), clarithromycin (17.03%), tetracycline (10.11%), amoxicillin (13.43%), levofloxacin (16.83%), ciprofloxacin (23.27%), and furazolidone (13.58%). In the current review, we showed that the prevalence of antibiotic resistance among H. pylori strains increased between the antibiotics mentioned in Iran during the years 1997-2017. It has been emphasized that prescribing an appropriate regimen for successfull eradication of H. pylori requires sufficient information on bacterial antibiotic susceptibility in different geographical areas.

Colonoscopy is a valuable diagnostic method that patients are not willing to undergo because of the fear of its complications. The purpose of this study was to determine the effect of intravenous fluid therapy prior to colonoscopy on blood circulation parameters and pain in patients and duration of Colonoscopy. This randomized clinical trial was conducted on 60 patients referred to the Endoscopic Department of Ghaem Hospital in Mashhad in 2016. Elderly people were randomly assigned to two groups of 30 as control and intervention groups. Patients in the intervention group received one liter of solution 1/3 normal saline, 2/3 D5W, one hour before colonoscopy. Before and 1, 3, 5, 9, and 10 minutes after colonoscopy, arterial blood oxygen saturation, heart rate, and blood pressure in both groups were measured and recorded in the checklist. 2 hours later, the patients’ pain levels were measured by Circulation Parameters checklist. The numerical value of pain was measured, and the durations of colonoscopy in both groups were also measured and recorded by a timer. The mean age of the patients in the intervention group was 38.4 ± 13.6 years and in the control group was 44.2 ± 14.4 years. The results of post start colonoscopy stage showed that there was a significant difference between the two groups in the mean arterial oxygen saturation after 5 and 9 minutes of fluid therapy (p < 0.001), systolic blood pressure 1 and 10 minutes after fluid therapy (p = 0.047), and diastolic blood pressure 5 minutes after the fluid therapy (p = 0.049). The mean duration of colonoscopy in the intervention group (18.15 ± 4.21 min) was significantly lower than the control group (22.13 ± 5.29 min, p = 0.002). Also, the mean pain score 2 hours after colonoscopy was significantly lower in the intervention group (1.53 ± 1.65) compared with the control group (3.26 ± 3.24, p = 0.010). The results of this study indicate the positive effect of fluid therapy prior to the onset of colonoscopy on the patients’ circulatory parameters, the duration of colonoscopy, and the patients’ pain. Therefore, with this effective, cost-effective, and safe intervention, patients can have a better experience in performing this diagnostic test.

Excessive bacteria and nutrient malabsorption are the two major events need to clarify small intestinal bacterial overgrowth (SIBO). Clinically, SIBO is defined as a condition with the existence of > 106 colony-forming units (CFU) bacteria in the human intestine. It is the only generally accepted criteria to diagnose the SIBO in clinical practice. The main problem is that several clinical disorders are happening in patients with SIBO; thus actual discrimination will be relatively difficult. Exploration of the current status of SIBO management and suggesting rifaximin as a main clinical target is our optimal goal. Although the quality of performed randomized clinical trials needs to be re-evaluated, rifaximin seems the only suitable option for treatment of SIBO. Undoubtedly, new treatment should include the correction of ongoing small intestinal microflora with proper antibiotic therapy. Personalized medicine is another option that should be studied thoroughly before entering the area of SIBO treating using proton pump inhibitors. Finally, we have to focus on the available option to have better management of patients with SIBO.

Inflammatory bowel disease (IBD) including ulcerative colitis (UC) and Crohn's disease (CD), as an autoimmune disorder, is associated with chronic relapsing inflammation of intestine. UC and CD are associated with gastrointestinal and extra-intestinal symptoms, which may vary in severity of clinical presentation. This study was designed to evaluate airway resistance and pulmonary volumes and capacities in the active phase of UC and CD. Patients who had IBD and referred to Shahid Modarres Hospital from February 2016 to December 2017 were assessed for enrollment in our study. Diagnosis of Crohn's disease or ulcerative colitis was confirmed by colonoscopic and pathological evaluations. Pulmonary respiratory parameters including first second of forced expiration (FEV1), forced vital capacity (FVC), residual volume (RV), total lung capacity (TLC), forced expiratory flow between 25% and 75% (FEF25-75%), and airway resistance were measured by plethysmography in the first days of admission in patients with stable IBD and also immediately after an initial stabilization of the vital signs in patients with unstable IBD. Data were analyzed using SPSS software (v.21. IBM Inc. IL). P value less than 0.05 was considered as statistically significant. Of 75 patients with IBD, 65 had UC and 10 had CD. The mean ages of the patients with UC and CD were 37.81 ± 13.31 and 34.20 ± 8.53 years, respectively. Of all the participants, approximately 54.7% and 45.3% of the patients were male and female, respectively. The duration of disease for patients with UC and CD was 43.09 ± 45.86 and 44.40 ± 15.45 months, respectively. Based on the Pearson correlation analysis, there were significant associations between FEV1, TLC, and FEF25-75% with the duration of UC and also between FEV1, RV, and airway resistance with the duration of CD. In patients with CD but not in the patients with UC, there were statistical relationships between FEV1, FVC, FEV1/FVC, RV, RV/TLC, FEF25-75% and increased airway resistance with severity and activation of IBD. According to our findings, pulmonary involvements were found often in patients with IBD with and without the presence of clinical pulmonary symptoms. The duration and also activation and severity of IBD can be associated with increased risk for pulmonary involvements.

Ulcerative colitis is a chronic and recurrent inflammatory disease characterized by the inflammation of the colon mucous membrane, causing abdominal pain, diarrhea, and hematochezia. Colonoscopy is considered as the method of choice for the diagnosis of this disease. Furthermore, the severity of this condition in the relapse periods is determined based on clinical and laboratory criteria. Regarding this, the present study aimed to investigate the relationship between faecal calprotectin level, a cytosolic protein of neutrophils and macrophages, and the severity of disease in patients with ulcerative colitis relapse. This cross-sectional study was conducted on 65 patients (i.e., 35 men and 30 women) with ulcerative colitis relapse. The results of clinical, laboratory, and colonoscopy examinations were collected using a checklist. Data analysis was performed using MED Cal statistical software (version 8). According to the results, the mean age of the participants was 36.31 ± 14.19 years. Out of the 65 patients, 26 (40%), 21 (32.3%), and 18 (27.7%) subjects had mild, moderate, and severe types of the disease, respectively. White blood cell count and erythrocyte sedimentation rate showed a significant decrease by the enhancement of disease severity and hemoglobin level (p < 0.001). Furthermore, the mean level of faecal calprotectin showed a significant elevation with the increase of the disease severity. The calprotectin level of > 387 μg/g with the sensitivity and specificity of 76.9% and 92.3%, respectively, was considered as indicating moderate and severe involvements. Faecal calprotectin level can be used as a non-invasive and reliable method to evaluate the severity of ulcerative colitis relapse.

Neuropsychiatric factors play important roles in symptoms of irritable bowel syndrome (IBS). Mood disorders such as bipolar disorder are prevalent among patients with IBS. Antidepressants are used traditionally for management of IBS symptoms but antibipolar agents have not been studied. Aripiprazole, an antibipolar agent, was selected because of having the least anticholinergic side effects. 147 patients with diagnosis of IBS were included in the study. Randomly selected 74 patients took nortriptyline 10 mg/day and 73 patients received aripiprazole 5 mg/day. Birmingham IBS Symptom Questionnaire for assessing the severity of IBS symptoms and Mood Disorder Questionnaire for diagnosis of bipolar mood disorder were filled by all the patients in the base time and then by 52 and 41 patients in month 1 and 40 and 28 patients in month 3, respectively. Two groups and subgroups of bipolar and nonbipolar disorders were compared in regard to the severity of IBS during follow-up visits. Decreases in mean scores were significant in both aripiprazole and nortriptyline groups during follow-up visits, but comparing the groups, the changes were more in aripiprazole group compared with nortriptyline group, although the differences were not significant (p > 0.05). The decrease in mean score was significant in both bipolar and non-bipolar subgroups during the follow-up visits, but the changes were only significant in bipolar subgroup of aripiprazole group (p < 0.05). Overall, aripiprazole has the same efficacy of nortriptyline in decreasing IBS symptoms but it is significantly more efficient in subgroup of patients with bipolar disorder. More and larger studies are needed for confirming the results of this study.

Primary intestinal lymphangiectasia is a rare congenital disorder leading to edema, hypoproteinemia, lymphocytopenia, and watery diarrhea. We here report a case of primary intestinal lymphangiectasia in a woman with peripheral edema and recurrent diarrhea in whom laparoscopic biopsy confirmed the diagnosis. In this report, a 21-year-old woman was referred to a tertiary hospital because of abdominal pain, lower extremity edema, and a history of chronic watery diarrhea from childhood. The patient was diagnosed as having protein losing enteropathy secondary to intestinal lymphangiectasia. Diagnosis was confirmed by laparoscopy and multiple deep intestinal biopsies were performed. The diagnosis of primary intestinal lymphangiectasia is usually neglected especially in adults. This differential diagnosis should be considered in any patients with a history of chronic diarrhea and hypoproteinemia. The correct clinical suspicion can properly guide physicians to the correct diagnosis. Diet intervention is the cornerstone of the medical management of primary intestinal lymphangiectasia, which is affected strongly with timely diagnosis.