Middle East Journal of Digestive Diseases
Volume:11 Issue: 3, Jul 2019

Clostridium difficile is the major causative agent of nosocomial antibiotic-associated colitis. The gold standard for C. difficile detection is stool culture followed by cytotoxic assay, although it is laborious and time-consuming. We developed a screening test based on a two-step conventional polymerase chain reaction (PCR) approach to detect gluD, the glutamate dehydrogenase (GDH) enzyme gene, which is a marker for screening of C. difficile. Targeting gluD comparing to the conserved stable genetic element of pathogenicity locus (PaLoc), with an accessory gene of Cdd3, was an effective method for the detection of this pathogen from patients with enterocolitis. Fresh fecal samples of the patients who were clinically suspicious for antibiotic-associated colitis were collected. Stool specimens were cultured on the cycloserine-cefoxitin fructose agar (CCFA) in an anaerobic condition, following alcohol shock treatment and enrichment in Clostridium difficile Brucella broth (CDBB). On confirmed colonies, PCR was carried out for detection of PaLoc subsidiary gene, Cdd3, and toxicogenic genes, tcdA and tcdB. The gluD that is GDH gene detection was performed by conventional PCR on the extracted DNA from 578 fresh stool samples. 57 (9.8%) strains of C. difficile were approved by conventional PCR for gluD and Cdd3 genes, in which 37 (6.4%) colonies had tcdA+/tcdB+ genotype, 2 (0.3%) tcdA+/tcdB-, 4 (0.7%) tcdA-/tcdB+ and the remaining 14 (2.4%) colonies were tcdA and tcdB negative. These results demonstrate that targeting gluD by PCR is quite promising for rapid detection of C. difficile from fresh fecal samples. Furthermore, the multiple-gene analysis for tcdA and tcdB assay proved a reliable approach for diagnosing of toxigenic strains among clinical samples.

Hepatic dysfunction has been associated with poor prognosis in critically ill patients. We aimed to investigate the incidence of early liver dysfunction and its association with probable predictive variables in a group of Iranian patients. The study was conducted on 149 pediatric patients referred to the pediatric intensive care unit (PICU), Shiraz University of Medical Sciences, Shiraz, Iran between April and October 2016. Serum levels of liver aminotransferase, alkaline phosphatase, total bilirubin, direct bilirubin, and international normalized ratio (INR) were recorded in 24, 48, and 96 hours after admission. On the first day of admission, direct bilirubin was the least (9.1%) and abnormal alkaline phosphatase level was the most (66.9%) common abnormalities. Abnormal levels of all tests except alkaline phosphatase were predictive of increased rate of mortality. In univariable logistic regression, abnormal aminotransferases (ALT and AST), INR, total bilirubin, and direct bilirubin had significant relationship with patients’ mortality after 24, 48, and 96 hours. In multivariable logistic regression only ALT and INR in the first 24 hours had significant relationship with mortality in final model. Although univariate logistic regression revealed a significant relationship between AST and ALT levels with PICU length of stay, no significant relationship was observed between these variables and PICU length of stay (except AST in the first 24 hours) in multivariable analysis. Increase in liver enzymes may predict mortality and increased PICU length of stay in critically ill children.

Gastrointestinal endoscopic procedures are widely used for diagnostic and therapeutic measures. Analgesia and sedation/anesthesia are inseparable parts of these studies and their related complications are inevitable. In a retrograde descriptive study in Shahid Beheshti Hospital, affiliated to Qom University of Medical Sciences, Qom, Iran from March 2013 to March 2017, we gathered information regarding common anesthesia related complications and analyzed them. 44659 procedures were performed during the study period and records of 21342 men (47.79%) and 23317 women (52.21%) were evaluated. Hemodynamic instability (9998; 22.39%), dysrhythmia (1600; 3.58%), desaturation (608; 1.36%), prolonged apnea (34; 0.08%), aspiration (43; 0.10%), postoperative nausea and vomiting (PONV) (636; 1.42%), headache (106; 0.24%), delirium (51; 0.11%), aphasia (1; 0.00%), masseter muscle spasm (1; 0.01%), myocardial infarction (2; 0.00%), and death (5; 0.01%) were seen in the patients. Sedation/anesthesia is enough safe in gastrointestinal endoscopic procedures to enhance the patients’ satisfaction and cooperation. If anesthesia with spontaneous breathing and unsecure airway is selected for this purpose, vigilance of anesthesia provider will be the key element of uneventful and safe procedure.

Echinococcus granulosis is a parasitic infection most commonly involving the liver. Iran is a hyperendemic area for this disease according to WHO. Despite improvements in medical and interventional radiological techniques, surgery remains the gold standard of treatment; however evidence on different surgical modalities were explained. Considering the high population of referring patients presenting to Omid and Ghaem Hospitals, Mashhad, Iran, we decided to compare the complications of our modified technique with routine technique in hydatid cyst surgery. 56 patients with hydatid cyst of the liver who underwent modified and routine surgical treatment in Ghaem and Omid Hospitals Mashhad, Iran were studied during Aug 2013- Nov 2015. 27 patients underwent modified surgical technique, whereas the remaining 27 patients were treated by using routine surgical method. These two groups of patients were compared with each other according to their postoperative length of hospital stay and resulting complications. The mean age of our patients was 41 years. 27 patients were male and 29 were female. Our results showed no statistically significant difference regarding the incidence of postoperative complications between the two groups. However, mean length of hospital stay was significantly different between the groups (4.5±1.87 and 7.6±2.25 days, respectively, p<0.001). The method of modified surgery with closed cyst drainage, which does not use external drains, is a safe surgical modality in the treatment of hydatid cyst disease of the liver if applied properly on appropriate patients.

Despite the fact that there is theoretical evidence about the association between unconscious defense mechanisms and irritable bowel syndrome (IBS), experimental evidence in this regard is limited. The aim of the present study was to compare the defense mechanisms used by the patients with IBS and a control group, and to investigate the relationship between these mechanisms with the severity of the disease and patients’ quality of life. Fourty-five patients with IBS (mean age of 37.1 years; 14 males) and 45 controls (mean age of 38.0 years; 13 males) were evaluated. IBS diagnosis was determined based on Rome III criteria and the predominant pattern of the disease was determined based on the patient's history (13 diarrhea-predominant, 16 constipation-predominant, and 16 alternating IBS). Defense Style Questionnaire-40, IBS Severity Scale, and IBS-Quality of Life questionnaire were used. The mean scores of projection, acting-out, somatization, autistic fantasy, passive-aggression, and reaction formation in the IBS group were significantly higher than the control group and the mean scores of humor and anticipation mechanisms were higher in the control group. There was no significant correlation between the score of defense mechanisms and the severity of IBS and the patients’ quality of life. The severity of immature defenses in the IBS group was significantly higher, whereas the severity of mature defenses was higher in the control group. These defenses were not correlated with the severity of IBS. Considering the limited sample size, these relationships need to be more investigated.

Anorectal melanomas are exceptionally uncommon and only 30% of anorectal melanomas are amelanotic. We report here a case of an anorectal amelanotic melanoma in a female patient. An 84-year-old patient complained of anal mass for 3 months. On examination, there was a 7.0 cm mass prolapsing through the anus that was pale-pink in color. Abdominal, pelvic, and chest computed tomography (CT) showed rectal wall thickening with an eccentric polypoid soft tissue density mass, and left inguinal and presacral lymph node enlargement along with a small nodule in the lower lobe of the left lung, likely representing metastatic deposit. Microscopic examination revealed a piece of skin with hyperplastic squamous epithelium with surface ulceration. The dermis and underlining tissue were showing infiltration by malignant sheets and nests of ovoid and spindle shape cells with prominent nucleolus and high mitotic figures. Immuno-staining for HMB-45, S-100, and Melan-A was positive, and it was negative for P63, CK 5/6, and Pan-CK, thus confirming it as an anorectal amelanotic melanoma, and not an epithelial tumor. This is the first case of an amelanotic anorectal melanoma reported from Saudi Arabia.

A few cases with esophageal bezoar have been reported in achalasia. We describe here a rare case of esophageal pharmacobezoar after ingestion of ferrous sulfate capsules in a patient with achalasia.
A 29-year-old woman presented with severe dysphagia since five days earlier. She had history of achalasia since 3 years ago but had refused any treatment option. After about 3 weeks of ferrous sulfate capsules ingestion, she developed severe dysphagia and was referred to a gastroenterologist. Physical examination was unremarkable. A barium swallow revealed dilated esophagus and bird's beak appearance. Esophagogastroduodenoscopy (EGD) showed dilated esophagus and soft black color bezoar in distal part of esophagus. The bezoar was retrieved with basket. In the next endoscopic session, achalasia balloon dilation was successfully applied.
Ferrous sulfate capsules can cause pharmacobezoar in patients with achalasia. Esophageal bezoar should be considered in differential diagnosis of untreated achalasia and acute exacerbation of dysphagia.

A 79-year-old man presented to emergency department with the complaint of abdominal pain and vomiting since two days earlier. He had no history of abdominal pain or gastrointestinal disease. On physical examination, he was dehydrated and a significant distension was noted in the upper abdomen. Plain radiograph y showed a dilated stomach. Computed tomography a showed dilated stomach with a twist pattern (Figures 1, 2).