Middle East Journal of Digestive Diseases
Volume:3 Issue: 1, Jan 2011

Colonoscopy is typically performed with sedation. Intravenous benzodiazepines with or without opioids have long been used to induce sedation for both colonoscopy and more complex endoscopic procedures. In recent years, we have observed a rapid transformation from the use of opioids and benzodiazepines to sedation with propofol in Western countries.1 However, most endoscopy centers in the Middle East still use traditional sedation with opioids and benzodiazepines for endoscopy. The safety, feasibility and effectiveness of propofol sedation for endoscopic procedures have been well studied in Western countries.

Celiac disease (CD) was traditionally believed to be a chronic enteropathy, almost exclusively affecting people of European origin. Celiac disease is the permanent intolerance to dietary gluten, the major protein component of wheat. The availability of new, simple, very sensitive and specific serological tests has shown that CD is as common in Middle Eastern countries as in Europe, Australia and New Zealand where the major dietary staple is wheat. A high prevalence of CD has been found in Iran, in both the general population and the at-risk groups, i.e. patients with type 1 diabetes or irritable bowel syndrome (IBS). In developing countries, serological testing in at risk groups is necessary for early identification of celiac patients. Clinical studies show that presentation with non-specific symptoms or a lack of symptoms is as common in the Middle East as in Europe. Wheat is a major component of the Iranian diet and exposure to wheat proteins induces some degree of immune tolerance, leading to milder symptoms that may be mistaken with other GI disorders. The implementation of gluten free diet (GFD) is a major challenge for both patients and clinicians in Iran, especially since commercial gluten-free products are not available in this area.

Hepadnaviruses employ an unusual strategy for the production of enormous number of virions during replication which makes rapid and substantial genetic sequence changes and alterations. The pathogenesis and clearance of hepatitis B virus (HBV) infection are engaged by the selection and expression of viral mutants during virus-host interactions. Mutations in regulatory regions such as the basal core promoter (BCP) which is thought to be related to lower production of hepatitis B “e” antigen (HBeAg) directly affects the clinical presentation of liver disease. However, the molecular structure of these mutations in chronic carriers has not been adequately evaluated. In this review we evaluate the molecular aspect and pathologic basis of basal core promoter mutations.

Gastric dysplasia (GD) is a precursor lesion of gastric adenocarcinoma. Intestinal type gastric carcinoma commonly shows microsatellite instability (MSI) and the diffuse type is associated with down regulation of E-cadherin. HER-2/neu is over-expressed in some cases of gastric cancer. In this study, MSI and expression rates of HER-2/neu and E-cadherin in GD were evaluated. Methods Paraffin blocks of 21 cases of low grade dysplasia (LD), 11 cases of high grade dysplasia (HD) and 25 cases of indefinite for dysplasia (ID) were collected. After deparaffinization and antigen retrieval, the sections were incubated with antibodies against E-cadherin, hMLH1, hMSH2 and HER-2/neu. The streptavidin- biotin complex method was used followed by peroxidase enzyme development with diaminobenzidine. HER-2/neu was positive in six cases of HD (50%), four LD (21%) and two ID (9%). E-cadherin was absent in two cases of LD and showed normal expression in all HD and ID cases. hMLH1 expression was absent or markedly decreased only in the zones of dysplasia in HD (3/11), LD (3/21) and ID (4/25). Absence or diminished expression of hMSH2 was seen in HD (3/11), LD (2/21) and ID (3/25) cases. HER-2/neu expression showed close association with diminished expression of hMLH1 or hMSH2 (p < 0.05). Conclusion Stepwise increase in the expression rate of HER-2/neu was seen in ID, LD and HD cases implying its role in cancer evolution. The absence of hMLH1 and hMSH2 in GD may predispose individuals to over-expression of other oncogenes such as HER-2/neu. Abnormal expression of E-cadherin is not a frequent finding in GD.

Esophageal squamous cell carcinoma (ESCC) is usually detected in advanced stages resulting in a very poor prognosis. Early diagnosis needs identification of clinically relevant precancerous lesions which could become the target of screening and early treatment. Our aim was to check whether esophagitis could serve as a relevant histological precursor of ESCC in Northern Iran. Methods During 2001–2005, all adult patients who were referred to Atrak clinic for upper gastrointestinal endoscopy and biopsy were enrolled. Atrak clinic is a major center for upper gastrointestinal cancer research in eastern Golestan. All subjects had been complaining of upper GI symptoms and were under further investigation to rule out cancer. Biopsies from the endoscopically normal mid-esophagus and also just above the esophago-gastric junction were obtained in all subjects whose esophagus appeared normal during endoscopy and from endoscopically normal appearing mucosa at the proximal vicinity of any detected mass. Microscopic examinations for the verification of the presence or absence of esophagitis was performed by independant histological examination of the samples by two pathologists. All the discrepant diagnoses were resolved in joint diagnostic sessions. Resultsts During the study period 836 patients were enrolled including 419 non cancer patients (endoscopy clinic controls), 387 cancer patients, and 30 subjects with clinical diagnosis of malignancy referred for histological reconfirmation of diagnosis by repeated biopsy. Mild or marked mid-esophagitis was diagnosed in 39 (9.3%), 47 (12.5%) and 12 (40%) of endoscopy clinic controls, cancer patients and those who were suspicious for upper gastrointestinal malignancies. Conclusion Our observation does not show evidence for esophagitis to be a predisposing factor for ESCC in Gonbad region In North Eastern Iran.

Training in internal medicine has significantly evolved alongside the development of science, technology and new facilities during the past fifty years. After the specialty of internal medicine, there are multiple subspecialty training programs which have started since 1985 in the Islamic Republic of Iran. In this manuscript we want to define the characteristics of the gastroenterology subspecialty training program in our country. Methods The characteristics of approved gastroenterology training centers were gathered through a questionnaire. The questionnaire was consisted; the establishment date, the number and academic rank of trainers, the number of trainees, hospital beds, the number and types of diagnostic and therapeutic procedures in a year, the characteristics of training programs and their curriculum composition. The collected data was discussed and revised in a focused group of gastroenterologists from training centers and the board members of Iranian Association of Gastroenterology and Hepatology (IAGH). Resultsts There are 11 training centers with 94 trainers and 65 trainees, with a ratio of trainers to trainees of 1.36. Fifty four percent of trainers are assistant professor. Yearly, 36 new fellows are admitted. Four centers have adequate facilities for training in advanced gastroenterology, and in three centers there are facilities for liver transplantation. The duration of training in internal medicine is four years, whereas in gastroenterology it is two years. The admission for this subspecialty is not university based and with other subspecialty programs, there is a national entrance examination. Conclusion There are adequate well known training centers with a suitable ratio of trainer to trainee in the Islamic Republic of Iran. The duration of the GI fellowship is short and implementation of post subspecialty programs for completing the required capabilities of fellows is necessary. The capacity of fellowship admission should be revised according to needs of the country in the fields of health maintenance, research and medical education programs.

Propofol is used as a sedative drug during colonoscopy. In this study we analyzed the adverse effects of propofol (i.e., hemodynamic and respiratory) on patients who underwent colonoscopies. Methods This study was performed in Qom Province, Iran. In this study, 125 patients (63 females, 62 males) were enrolled. Study patients were administered (0.5-1.5 mg/kg) intravenous propofol by an anesthesiologist. Oxygen saturation and blood pressure were recorded at three minute intervals. We used the American Society of Anesthesiology (ASA) classification to stratify patients by risk prior to the procedure. For statistical analysis, the chi-square and paired t-tests were used. A p-value less than 0.05 was considered significant. Resultsts Patients’ mean age was 45.36 ± 16.19 years. ASA-I comprised 25.6% of study patients and 74.4% were categorized as ASA-II. Hypopnea occurred in 56.8% of patients and was prolonged in 32.4%. Of the study patients, 5.6% developed hypoxemia which was successfully controlled by the administration of nasal oxygen and no need for mechanical ventilation. The mean arterial blood pressure (p < 0.0001), oxygen saturation (p < 0.0001) and heart rate (p < 0.0001) significantly decreased during colonoscopy. The occurrence of hypopnea significantly increased in patients with pre-procedure oxygen saturation levels ≤ 95% (p < 0.02), age ≥50 years (p < 0.0001) and ASA class II (p < 0.0001) Agitation, hypotension and cough were seen in 1.6%, 1.6% and 0.8% of patients, respectively. Conclusion Propofol has a short half life that enables faster recovery of normal neurologic and social functions we recommend the use of propofol under supervision of anesthesiologist or a trained gastroenterologist.

Familial Mediterranean fever (FMF) is an autosomal recessive disorder characterized by sporadic, paroxysmal attacks of fever and serosal inflammation. Although the disease usually begins before the age of 20 years, we aimed to evaluate the demography, clinical features and treatment outcome of familial Mediterranean fever in Iranian adult patients above 20 years old. Methods In this cross-sectional study, adult patients (first attack at the age of >20 years) with a diagnosis of FMF who referred to the gastroenterology and rheumatology Clinics of Ardebil University of Medical Science (situated in north west of Iran) over the period of 2004-2009 were enrolled. FMF diagnosis was based on clinical criteria. R esults Forty four FMF patients (30 male and 14 female) with the mean [± Standard Deviation (SD)] age of first attack of 29 ± 7.8 years were enrolled. Abdominal pain (95.5%) and fever (91%) were the most common clinical findings. All of the patients had satisfactorily responded to therapy. Response was complete in 76.7% and partial in 23.3% of the patients. There was no clinical or laboratory evidence of amyloidosis at the time of diagnosis or during follow-up. Conclusision Our findings demonstrated that adult-onset FMF in Iran has different characteristics (more common in males, lesser prevalence of arthritis and erysipelas-like erythema, less delay in diagnosis) and treatment outcome (favorable response even to low-dose colchicine) in comparison with the previous data on early onset patients.

The ampulla of Vater is commonly located in the posteromedial wall of the second portion of the duodenum. At times, the ampulla of Vater may be found at uncommon sites such as the third and fourth portions of the duodenum, the duodenal bulb and the stomach. We found the ampulla of Vater in the pyloric channel in a 44 year old patient who had undergone surgery for acute cholecystitis. An intra-operative T-tube cholangiography revealed distal narrowing. The major papilla was not found during endoscopic retrograde cholangiopancreatography (ERCP) and a more accurate T-tube cholangiography revealed that the common bile duct opened in the distal stomach, probably in the pylorus. Finally the ampulla opening was located in the pylorus by methylene blue injection through the T-tube at endoscopy. This rather unusual location of the ampulla of Vater has implications for gastroenterologists performing ERCP.

A 56 year-old man with recurrent gastrointestinal bleeding is reported. The patient had constant crampy pain in his epigastrium, right upper quadrant and periumbilical area. Upper-gastrointestinal endoscopy was normal. Colonoscopy showed a soft-tissue mucosal lesion in the rectum which was determined to be a worm that extended into the lumen of the rectum with no bleeding. The pathology was microfilaria in the rectal glands. Filariasis should be taken into consideration in the differential diagnosis of recurrent gastrointestinal bleeding conditions in our area.

In this article, we describe some features of a rediscovered medical text written in old Persian (Farsi Dari) over one thousand years ago and discuss some of its significant attributes in relation to the historical background of the Iranian scientific and literary renaissance of that era.