Middle East Journal of Digestive Diseases
Volume:12 Issue: 4, Oct 2020

Celiac disease (CeD) is a widespread autoimmune enteropathy caused by dietary gluten peptides in genetically susceptible individuals, which includes a range of intestinal and extraintestinal manifestations. Currently, there is no effective treatment for CeD other than strict adherence to a gluten-free diet (GFD). However, persistent or frequent symptoms and also partial villus atrophy were observed in some patients with CeD due to intentional or inadvertent gluten exposure during the use of GFD. It means that GFD alone is not enough to control CeD symptoms and long-term complications. Accordingly, new therapeutic approaches for CeD treatment such as gluten proteolysis, removing gluten from the digestive tract, promoting tight junction assembly, inhibiting intestinal tissue transglutaminase 2, using probiotics, and developing immunotherapeutic methods have been proposed through different strategies. This review focused on discussing the novel therapeutic strategies for CeD management.

BACKGROUND The COVID-19 pandemic has affected the health care infrastructure dramatically, with abundant resources necessarily being redirected to COVID-19 patients and their care. Also, patients with chronic diseases like inflammatory bowel disease (IBD) may be affected in several ways during this pandemic. METHODS We used the Iranian registry of Crohn’s and colitis (IRCC) infrastructure. We called and sent messages to follow-up and support the care of all registered patients. Besides, we prepared and distributed educational materials for these patients and physicians to reduce the risk of COVID-19 infection. We risk-stratified them and prepared outpatient clinics and hospitalization guidance for IBD patients. RESULTS Of 13165 Iranian patients with IBD, 51 have been diagnosed as having COVID-19. IBD patients made 1920 hotline calls. Among the patients with suspicious presentations, 14 COVID-19 infections were diagnosed. Additionally, 1782 patients with IBD from five provinces actively phone-called among whom 28 definite cases were diagnosed. CONCLUSION IBD patients’ follow-up could help in diagnosing the affected IBD patients with COVID-19. Additionally, the performance of protective actions and preparing the patients and physicians for decisive proceedings are the principles of protection of IBD patients.

BACKGROUND:

 Cholangiocarcinoma is the second most common malignant liver cancer. Its early diagnosis plays an important role in the success of treatment. The aim of this study was to compare the use of cold forceps biopsy without cholangioscopy with brush cytology in the diagnosis of cholangiocarcinoma. 

METHODS: 

In this prospective study, we enrolled 19 patients. Endoscopic retrograde cholangiopancreatography (ERCP) was performed for all individuals. Sampling was performed from the narrowing site using the brush method. Then, a cold forceps biopsy was performed under fluoroscopy. RESULTS The mean age of the patients was 63.31 ± 11.12 years and most of them were men (63.16 %). The brush cytology and the cold forceps biopsy diagnosed 31.85% and 68.42% of the samples as cholangiocarcinoma, respectively. According to the McNemar test, there was a statistically significant difference between the diagnostic results of the brush cytology and cold forceps biopsy. So that more cholangiocarcinoma cases were diagnosed using forceps biopsy (p = 0.016). No complications such as perforation, bleeding, cholangitis, and leakage were reported during the cold forceps procedure. 

CONCLUSION:

 Cold forceps biopsy under fluoroscopy is better than cytology brush in the diagnosis of proximal cholangiocarcinoma. It is recommended to be used as a low-cost alternative in cases where cholangioscopy is not available.

 In the Middle East, data on liver transplantation (LT) are limited, and reports on LT from this region are of specific value. The purpose of this study is to report our 8-year experiences and challenges with LTs in our center to improve the outcomes.

 116 patients received whole organ graft from deceased donors, and orthotopic liver transplantation was performed at Taleghani hospital, between January 2009 and July 2017. The patients were prioritized according to Model for End-Stage Liver Disease (MELD) score and Child-Pugh classification.

 The most common postoperative complication was sepsis (16%), although the most common surgical post LT complication was postoperative bleeding. The most common cause of death was primary graft dysfunction (21.9%). Following LT, 50% of the deaths (n=16) occurred during the first 10 days. Cumulative survival rates were 78.4%, 77.6%, and 66.7% at 1 month, 1 year, and 5 years, respectively.

This report provides invaluable experience from a region where data on LT is largely missing due to the absence of official registration programs. The data could be used to improve the LT program in the region.

 Understanding the associations among different disorders remarkably improves their diagnosis and treatments. Celiac disease is the most complicated and prevalent form of immune-mediated diseases. On the other hand, inflammatory bowel diseases lead to inflammation of the intestine with an unknown cause. Although inflammatory bowel diseases have been often thought of as an autoimmune disorder, they can be triggered by whatever that can lead to the inflammation in the whole bowel. Henceforth, both aforementioned diseases are related to autoimmune attacks and cause a sort of inflammatory event, which exploring trade-off among them supposedly will lead to discovering important genes and, in turn, to the possible common therapeutic protocols. In the current study, we aimed to determine the correlation between the common genes in celiac disease and inflammatory bowel diseases.

 314 and 851 genes correlated with celiac disease and inflammatory bowel diseases respectively extracted from DisGeNET were subjected to an in-silico data analysis framework to mine prognosticates genes and the associated pathways.

149 shared genes between these diseases regulated by highlighted transcription factors NFKB1, IRF1, STAT1, HSF1, GATA3 were characterized as discriminating molecules, which by further screening were enriched in pathways mostly involved in apoptosis, T cell activation, and cytokine, chemokine, and interleukin signaling.

We observed that the identified common genes were associated with a wide range of pathogenic mechanisms underlying these diseases.

 Proton pump inhibitors (PPIs) are the most potent gastric agents for most acid-related disorders. Their effectiveness has led to their overutilization, leading to potential risks on patients and significant economic implications.The aim of this study was to determine the frequency of PPI overuse in Lebanon. Hence, the economic impact of this overutilization, if proven to be present, can be inferred.
 

An epidemiological descriptive cross-sectional study was conducted in pharmacies all around Lebanese governorates over a 1-year period, using questionnaires handed out to 1000 participants coming to buy PPIs. Subjects taking PPIs for inappropriate indications or in inappropriate dosages or durations were considered abusing PPIs. PPIs are indicated for multiple gastric disorders and for prophylaxis of gastrointestinal injury when taking gastro-toxic medications.

71.4% of subjects were overusing PPIs. Approximately 25 million US dollars were being wasted annually. Three categories of overuse were inferred (indication, dosage, and duration). Gastro protection was the most common reason for taking PPIs. Demographic variables and doctors’ prescriptions did not influence PPI overuse.

PPIs are massively overused in Lebanon, leading to a huge burden on the
health care system. Adhering to evidence-based guidelines and educational programs is highly recommended to enhance the quality and efficiency of prescriptions.

This clinical investigation aimed to compare the efficacy of treatment of peptic ulcer hemorrhage by argon plasma coagulation (APC) via contact heat probe method (heater probe) along with epinephrine injection

100 patients who underwent endoscopic treatment, were randomly divided into two groups consisting of 50 patients each. In the first group, an intervention was performed using foot pedal and 2.3mm and 3.2mm argon probes placed in a 2 to 8 mm distance of delivery place leading to plasma coagulation, sufficient necrosis and hemostasis. In the second group, wound press contact probe was used for wound healing with 15 watts of heat for about 25 degrees, causing coagulation and hemostasis. To evaluate and compare the ulcer treatment in both groups, the patient progress results were monitored for a period of one month from the day of discharge. Statistical analyses of data were performed using SPSS software version 22 along with Chi-square test and T-test.

 No significant difference observed in two groups in term of age, sex and clinical symptoms, but patients treated with APC method had higher hemoglobin levels (p<0.001). The duration of intervention and abdominal bloating in APC group was significantly higher with two cases of re-admission. In HP group, 3 cases (6.3%) had treatment failure and an average transfused blood was significantly higher in the HP group (p<0.001).

Endoscopy treatment duration was significantly lower in patients treated with the HP method due to separate washing route. HP method seems to be more appropriate for treatment of cases with abdominal bloating, distal gastric lesion and HP bulbs.

 Currently, there is no published questionnaire translated in the Persian language for pruritus evaluation in patients with chronic liver disease. Therefore, it would be well worth having a valid and reliable Persian questionnaire for assessing pruritus with its different aspects. This study was designed to evaluate the validity and reliability of the translated version of the 12-Item Pruritus Severity Score (12-PSS)

The patients with pruritus due to chronic liver disease, who referred to the liver clinic affiliated to Tehran University of Medical Sciences, were enrolled in this cross-sectional study. Following the forward-backward translation of 12-PSS into Persian, the content validity index (CVI) and its reliability were assessed. The patients were asked to respond to the visual analog scale (VAS) along with 12-PSS on their visits to evaluate the correlation between them.

160 eligible patients were entered in the present study. The mean age was 46.03 (±13.05) years. The Cronbach’s alpha for all domains of 12-PSS was 0.81-0.92 (average 0.89), which showed a strong consistency. The mean VAS and 12-PSS were 5.47±2.55 and 11.71±5.25, respectively, and the correlation of VAS and 12-PSS was strong (p<0.05, r=0.89).

The Persian version of 12-PSS is a valid questionnaire for assessing pruritus and follow up response to treatment for patients with chronic liver disease.

A 22-year-old man who had suffered two attacks of brisk upper gastrointestinal bleeding (UGIB) within a month prior to admission was diagnosed as having hemobilia because of fistula formation between the hepatic artery and intrahepatic bile duct due to inflammation and abrasion. He was managed by surgery.

A 63-year-old man is referred to the Emergency Center with complaints of nausea, vomiting, and epigastric pain for 2 weeks. The patient occasionally mentions vomiting after meals and also complains of other symptoms such as bloating, heavy post-meal pain, and pain in the epigastric region with the vomiting. He notes that he has weight lost about 5 kg in the past three months. The pain in the epigastric area was worsened after eating, and following these symptoms, his appetite has decreased. The patient does not give a history of any particular disease. The patient’s vital signs are stable and are as follows: Blood pressure: 120/100 mm Hg pulse rate: 84/min respiratory rate: 18/min body temperature: 36.5°C The patient is generally pale in appearance but not icteric. The mucus was dry. In the clinical examinations, her abdomen was fatty, soft, and without distention. The patient had mild tenderness in the epigastric region, and no mass was touched. The rest of his examinations were normal. The patient’s laboratory findings indicate metabolic alkalosis. Table 1 summarizes the most important laboratory findings of the patient: Due to the patient’s nausea and vomiting and the diagnosis of the reason, we tried several times to insert the nasogastric (NG) tube, but we failed. The next diagnostic step we took was performing an endoscopy, which revealed the presence of a space lesion in the duodenal bulb that had closed most of the duct. A sample specimen was taken from the lesion and sent for pathological examination.