Middle East Journal of Digestive Diseases
Volume:5 Issue: 1, Jan 2013

Opium is one of the oldest herbal medicines currently used as an analgesic, sedative and antidiarrheal treatment. The effects of opium are principally mediated by the μ-, κ- and δ-opioid receptors. Opioid substances consist of all natural and synthetic alkaloids that are derived from opium. Most of their effects on gastrointestinal motility and secretion result from suppression of neural activity. Inhibition of gastric emptying, increase in sphincter tone, changes in motor patterns, and blockage of peristalsis result from opioid use. Common adverse effects of opioid administration include sedation, dizziness, nausea, vomiting, constipation, dependency and tolerance, and respiratory depression. The most common adverse effect of opioid use is constipation. Although stool softeners are frequently used to decrease opioid-induced bowel dysfunction, however they are not efficacious. Possibly, the use of specific opioid receptor antagonists is a more suitable approach. Opioid antagonists, both central and peripheral, could affect gastrointestinal function and visceromotor sensitivity, which suggests an important role for endogenous opioid peptides in the control of gastrointestinal physiology. Underlying diseases or medications known to influence the central nervous system (CNS) often accelerate the opioid''s adverse effects. However, changing the opioid and/or route of administration could also decrease their adverse effects. Appropriate patient selection, patient education and discussion regarding potential adverse effects may assist physicians in maximizing the effectiveness of opioids, while reducing the number and severity of adverse effects.

Acute pancreatitis is the most common serious complication of endoscopic retrograde cholangiopancreatography (ERCP) that can occasionally be fatal. Multiple drugs have been examined for the prevention of this side effect, with generally uncertain results. This study is an effort to prevent this complication by the use of oral N-acetyl cysteine (NAC).A total of 100 patients who were candidates for ERCP were divided ran­domly into two groups. In the NAC (N) group, patients received 1200 mg NAC with 150 cc water orally 2 h before ERCP. In the placebo (P) group, 150 cc water was prescribed as a placebo. We measured serum amylase and lipase levels before and 24 h after ERCP. The prevalence of pancreatitis and duration of admission in each group were determined and compared.In group N there were 5 (10%) cases of pancreatitis, whereas in group P there were 14 (28%) cases, which was significant (risk reduction ratio: 2.8; p=0.02).The average admission time was 1.16±0.55 days in group N and 1.18±0.44 days in group P, which was not significant.There were significant differences in the prevalence of acute pancreatitis between the two groups. In addition, the number of need to treat (NNT) con­sisted of five cases for NAC. With regards to the above results and the safety profile of NAC, it could be used as a therapeutic agent for the prevention of post-ERCP pancreatitis. We recommend that the results of this study be veri­fied by additional clinical trials.

The relationship between gastroesophageal reflux (GERD) and airway diseases is still a matter of debate. Oscillometry is an objective, independent tool for the evaluation of airway resistance. The main purpose of this study is to comparespirometry and oscillometry results before and after treatment by a proton pump inhibitor (PPI) in a group of GERD patients who have no respiratory symptoms. This study was performed on patients with endoscopically diagnosed reflux esophagitis who had no pulmonary symptoms. Patients received omeprazole 40 mg, twice a day for 12 weeks. Spirometry and oscillometry were performed before and after treatment. Impulse oscillometry (IOS) was performed by a force oscillation instrument. We recorded respiratory resistance at 5 Hz (R5) and 20 Hz (R20), resonant frequency (Fres), and distal capacitive reactance (X5) for each patient. Included were 30 patients (17 males; 13 females) whose mean age was 32 years. According to the Los Angeles Classification, 16 patients had grades B or C esophagitis and 14 had grade A. Although all patients had normal spirometry results, 50% had increased airway resistance according to oscillometric findings. After treatment with omeprazole, only 16.3% had abnormal oscillometry results (p=0.004). Spirometry results [forced expiratory volume at the first second (FEV1); forced vital capacity (FVC); FEV1/FVC; and mean forced expiratory flow 25%-75% (FEF 25%-75%)] showed significant further improvement compared to pretreatment normal values (p‹0.001 for all). Abnormal airway resistance may be present in GERD patients even when there is no obvious respiratory symptom. Oscillometry seems to be more sensitive than spirometry in reporting abnormal pulmonary function in patients with GERD.

Ulcerative colitis (UC), as the prototype of inflammatory bowel disease of the large bowel, is increasing in Iran and other developing countries. There are few studies that discuss the properties of this disease in the Islamic Republic of Iran. The result of this review may provide a general consensus about the epidemiological features of UC in Iran. This was a qualitative, systematic review that investigated the incidence, prevalence, and demographic properties of UC in Iran. We evaluated all published studies in the PubMed database, IranMedex, Magiran, and Scientific Information Database (SID) that pertained to the epidemiology and demographic features of UC in Iran from January1987 to January 2012. After searching with defined keywords and implementing the inclusion and exclusion criteria, 11 case series and 2 case-control studies fulfilled the criteria for inclusion.The estimated prevalence of UC is 15 per 105persons, and the reported incidences were 3.04 and 3.25 per 105 persons in two Iranian provinces. The disease was more commonly observed in women and people in their fourth decade of life. Cigarette smoking conferred protection and familial association seemed to be similar to developed countries. UC did not appear to be more common among the higher socioeconomic class. In addition it less commonly involved the proximal colon and rectum.Although the data is limited, the prevalence and incidence of UC in Iran shows an increasing pattern similar to other countries in the region. There is no clear association with socioeconomic status. Milder forms of the disease are common in Iran. A comprehensive nationwide data bank is needed for a better definition of the disease characteristics.

Esophageal cancer is highly prevalent among the Turkman people in North­eastern Iran. In order to evaluate its etiology, there is an on-going prospective cohort study in this area involving approximately 50000 subjects over the age of 40 years. The majority of these subjects are illiterate, thus obtaining in­formed consent is very important and difficult. Initially, we explained the aim and study method to religious leaders and health-sanitary officials. One week prior to obtaining informed consent, poten­tial participants were given adequate information about the research process by trained health personnel at their own home. Thus, participants had sufficient time to consider the research and consult with local health personnel, religious authorities, family, neighbors, friends and those who previously participated in the study. Potential participants could observe the research process directly and then be included in the study if they agreed.A total of 50045 individuals agreed to participate in the study, of which 70% were illiterate. There were no refusals due to the medical ethical aspects of this study.The method of awareness in this study can be a useful pattern for research on elderly and illiterate individuals who are participants in research studies in Iran and other countries.

Liver cirrhosis is one of the major causes of hospitalization and mortality in children. A wide spectrum of disorders including developmental abnormali­ties, infections, metabolic and genetic disorders can lead to liver cirrhosis in pediatric patients. Determination of its etiology is important for treatment mo­dality, prevention of progressive liver damage, family counseling and prioritiz­ing liver transplantation. The aim of this study is to evaluate the causes of liver cirrhosis in children in Southern Iran.We included all cirrhotic children aged less than 18 years who referred to an outpatient Pediatric Gastroenterology Clinic affiliated with Shiraz University of Medical Sciences between March 2009 and September 2010 in this cross-sectional study. The etiology of cirrhosis was determined according to clinical findings, laboratory tests, radiographic evaluation such as ultrasonography or computed tomography scan, hepatobiliary scintigraphy and histopathologic examination of the liver biopsy. Cirrhosis with unknown etiology was consid­ered as cryptogenic.A total of 106 cirrhotic children aged between 5 months to 18 years old with a mean age of 8.24 ± 6.12 years that included 60 boys (56.6%) and 46 girls (43.4%) were enrolled in the study. The most common causes of liver cirrhosis were Wilson disease (n=22; 20.7%), biliary atresia (n=19; 17.9%), and crypto­genic cirrhosis (n=14; 13.2%). Other causes were autoimmune hepatitis (n=12; 11.3%), idiopathic neonatal hepatitis (n=10; 9.4%), hepatorenal tyrosinemia (n=9; 8.5%), glycogen storage disease (n=6; 5.7%), and progressive familial intrahepatic cholestasis (n=4; 3.8%).Considering the most common etiology of liver cirrhosis in children in this part of Iran we suggest testing for Wilson disease in all cirrhotic children.

Gastrointestinal stromal tumors (GIST) are the most common mesenchy­mal tumors of the gastrointestinal tract. The biological pattern of these tumors ranges from benign-appearing small lesions to malignant sarcomas. Only 3%-5% of GISTs are found in the duodenum. A duodenal GIST is a rare source of upper gastrointestinal bleeding. A remarkable percentage of duodenal GISTs are localized in the third and fourth part of the duodenum and may not be no­ticed on standard upper endoscopy. Push enteroscopy is sometimes advisable to find these lesions. Surgical resection either limited or pancreaticoduodenec­tomy can be the treatment of choice. In general, adjuvant therapy with imatinib has been proved to extend survival in patients with GIST.The current case, a 24-year-old male, presented with acute upper gastroin­testinal bleeding from a submucosal ulcerated tumor located in the distal third part of the duodenum, 3 cm distal from the papilla of Vater. After primary care and blood transfusion in a local hospital, partial resection of the duodenum was performed as a definitive surgical therapy. Histopathology showed a GIST with a diameter of 3 cm and moderately malignant according to tumor grade, and ‹5 mitoses/10 high power field (HPF).

Ménétrier''s disease is a rare cause of hypertrophic gastropathy that is usually confined to the gastric body and fundus. It is characterized by giant rugae, hypoalbuminemia, and foveolar hyperplasia. Here we report the case of a 26-year-old woman who presented with epigastric pain, postparandial nausea-vomiting, and weight loss. Paraclinic evaluation revealed hypoalbuminemia and hypochromic microcytic anemia. Gastroscopy and barium meal study showed diffuse polypoid, nodular lesions that affected the entire stomach, invaginating into the duodenum, leading to partial duodenal obstruction. The histologic, radiologic and endoscopic findings fulfilled the diagnosis of Ménétrier''s disease. To the best of our knowledge, gastroduodenal intussusception by Ménétrier''s disease has been rarely described in the literature.