Middle East Journal of Digestive Diseases
Volume:9 Issue: 4, Oct 2017

Liver cirrhosis is a major chronic disease in the field of digestive diseases. It causes more than one million deaths per year. Despite established evidence based guidelines, the adherence to standard of care or quality indicators are variable. Complete adherence to the recommendations of guidelines is less than 50%. To improve the quality of care in patients with cirrhosis, we need a more holistic view. Because of high rate of death due to cardiovascular disease and neoplasms, the care of comorbid conditions and risk factors such as smoking, hypertension, high blood sugar or cholesterol, would be important in addition to the management of primary liver disease. Despite a holistic multidisciplinary approach for this goal, the management of such patients should be patient centered and individualized. The diagnosis of underlying etiology and its appropriate treatment is the most important step. Definition and customizing the quality indicators for quality measure in patients are needed. Because most suggested quality indicators are designed for measuring the quality of care in decompensated liver cirrhosis, we need special quality indicators for compensated and milder forms of chronic liver disease as well. Training the patients for participation in their own management, design of special clinics with dedicated health professionals in a form of chronic disease model, is suggested for improvement of quality of care in this group of patients. Special day care centers by a dedicated gastroenterologist and a trained nurse may be a practical model for better management of such patients.

Anatomical variations in the biliary system have been proven to be of clinical importance. Awareness of the pattern of these variations in a specific population may help to prevent and manage biliary injuries during surgical and endoscopic procedures. Knowledge of the biliary anatomy will be also of great help in planning the drainage of adequate percentage of liver parenchyma in endoscopic or radiological procedures.
All consecutive patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) from April 2013 to April 2015 at Nemazee Hospital, a referral center in the south of Iran, were included in this cross-sectional study. The patients with previous hepatic or biliary surgery, liver injury or destructive biliary disease were excluded from the study. All ERCPs were reviewed by two expert gastroenterologists in this field. The disagreed images by the two gastroenterologists were excluded. Huang classification was used for categorizing the different structural variants of the biliary tree, and the frequency of each variant was recorded.
Totally, 362 patients (181 men and 181 women) were included in the study. 163 patients (45%) had type A1 Huang classification (right dominant), which was the most prevalent type among our patients. 55% of them had non-right dominant anatomy. The result of the Chi-square test revealed that there was no statistically significant difference between the men and women regarding the anatomical variations (p=0.413).
The anatomical variation in the biliary system among Iranian patients is comparable to other regions of the world. Significant proportions of our patients are non-right dominant and may need bilateral biliary drainage.

One of the earliest diagnostic signs of hepatorenal syndrome in patients suffering from liver cirrhosis is an increase in the renal vascular resistive index (RI). In this study, the impact of propranolol on decreasing this index and to postpone the probability of hepatorenal syndrome has been investigated.
In the current research, 30 patients with liver cirrhosis with different age and sexes have been enrolled. Demographic data and complete medical history have been collected using a specific questionnaire. At first, renal artery Doppler ultrasonography was performed to determine the RI. The patients were then treated with propranolol, and under supervision, the dose of the drug was increased gradually every 3 to 5 days to reach the target of 25% decrease in resting heart rate. One month after reaching the target dose of the medicine, Doppler ultrasonography was repeated for the patients and the second RI was compared with the pretreatment ones.
According to our results after treatment with propranolol, a significant decrease of RI was observed (pPropranolol reduces renal vascular RI in patients with cirrhosis. The response rates in the patients with decompensating cirrhosis were significantly higher than the patients with compensating cirrhosis.

Ideal bowel preparation regimen for a suitable colonoscopy should be safe, and well tolerated, and should rapidly clear gastrointestinal tract. Soluble polyethylene glycol (PEG) is the most common cleansing drug and Senna or C-Lax (Cassia angustifolia Vahl) is an alternative herbal one. This study was designed to compare the efficacy of PEG and C-lax in bowel preparation.
In this randomized double blind trial (registry number in IRCT.ir: IRCT201601161264N7), 320 patients were randomly assigned in PEG or C-lax groups. PEG solution was prepared from 5×70 gr sachets in 20×250cc water (250 ml every 15 minutes), prescribed 24h before the colonoscopy. In the other group 3×60 ml C-lax syrup glasses (each containing 90 mg senozid B) was given in two divided doses (1.5 glasses of 250cc every 12 hours), 24h before the colonoscopy. Ottawa score was used to evaluate the quality of bowel preparation. Chi-square test, Student t test, Mann-Whitney test and multivariate analysis were used to analyze the data.
Of these patients with the mean (SD) age of 50 (15.16) years, 162 (50.8%) were men. Mean (SD) Ottawa score was 2.57 (0.2) and 3.15 (0.31) in the PEG and C-lax group, respectively (P value = 0.81). Multivariate analysis showed that less opium consumption (PC-Lax is non-inferior to PEG solution in cleansing colon. The quality of bowel preparation was lower in opium consumers and better in those with higher educational level.

BACKGROUNDRecent trials have shown controversial results on which enteral feeding methods has a lower risk of enteral feeding intolerance. Therefore, we aimed to compare two methods of bolus and intermittent feeding on enteral feeding intolerance of patients with sepsis.
METHODSThis triple-blind randomized controlled trial was conducted on 60 patients with sepsis, who were fed through tubes for at least 3 days. The patients were randomly assigned into bolus feeding, intermittent feeding, and control groups. Enteral feeding intolerance of all patients was recorded in 3 consecutive days by a researcher-made checklist including the data on gastric residual volume, vomiting, diarrhea, constipation, and abdominal distension.
RESULTSThere were no significant differences between the three studied groups in none of the intervention days pertaining to constipation, diarrhea, vomiting, abdominal distention, and gastric residual volume (p >0.05). Also, no statistically significant difference was found between all variables in the three studied groups during the 3 days (p >0.05).
CONCLUSIONAs enteral feeding intolerance of patients with sepsis was similar in both bolus and intermittent feeding methods, it can be concluded that bolus method can still be used as a standard method to decrease the risk of enteral feeding intolerance if it is used properly.

The effect of changes in intestinal microbiota on constipation is contraversial. Constipation is more prevalent in elderly. Therefore, the current study was designed to assess the role of modulating inflammatory cytokines in old age patients with constipation by evaluating the serum levels of tumor necrosis factor alpha (TNF-α), interleukin 1 (IL-l), and interleukin 6 (IL-6).
This case-control study was done on 100 participants, aged 65 years or higher, with and without functional constipation according to ROME III criteria (50 participants in each group). Baseline demographic, clinical characteristics, and serum levels of TNF-α, IL-1, and IL-6 were compared between the case and control groups. Independent t test and Chi-square test were used for analysis of data.
Mean levels of TNF-α, IL-1, and IL-6 were (666.80±101.40 pg/mL vs. 489.20±53.68 pg/mL, pThis study showed a significant association between the serum level of modulating inflammatory cytokines and age-related constipation in Iranian subjects. It seems that the serum level of modulating inflammatory cytokines can be affected by diversity and abundance in the gut microbiota. The role of diversity in microbial population and their abundance in gut must be evaluated in further studies.

Inflammatory bowel disease following a solid organ transplantation while the patient is receiving immunosuppressive therapy is a rare phenomenon. Here we present a 48-year-old man who underwent cardiac transplantation 9 years earlier and was receiving cyclosporine as immunosuppressive therapy since then, presenting with complaints of rectorrhagia and diarrhea. In follow-up, he was diagnosed as having ulcerative colitis. We also reviewed the literature for similar cases, which yielded very few similar ones.

Pancreatic tuberculosis is extremely rare and its clinical and radiological findings are similar to those of pancreatic malignancy. The diagnosis of pancreatic tuberculosis is not usually made prior to surgery. Here, we report a case of pancreatic tuberculosis, presented with abdominal pain and weight loss. Abdominal computed tomography (CT) showed a 102 mm×61 mm septate solid-cystic mass in the pancreatic head area with extension into the hilum of the liver. There was no evidence of inflammation or pancreatitis. Endoscopic ultrasound-fine needle aspiration (EUS-FNA) could not yield the diagnosis. Exploratory laparotomy and further pathological evaluation suggested pancreatic tuberculosis. Response to antituberculosis treatment confirmed the diagnosis. Finally, previous case reports and case studies of pancreatic tuberculosis in the literature are fully investigated.

A 19-year-old woman presented to our outpatient clinic with localized left upper quadrant (LUQ) pain since 5 months earlier. Intermittent attacks of abdominal pain that progressed to a constant pain and eventually led to shortness of breath were reported.
She had no complaints of fever, weight loss, dyspnea, nausea, vomiting, and altered bowel habits. There was no history of abdominal trauma or surgery. Her medical history was negative and physical examination was unremarkable. All laboratory tests were normal and serological test had no evidence of parasitic infection with echinococcusgranulosus.
Plain abdominal radiography was normal. Ultrasound examination showed splenomegaly and hypoechoic well defined intrasplenic cystic lesion.
Computed tomography revealed a cystic mass-like lesion measuring about 25×13×12cm with internal septa in the spleen with a rim of remaining splenic parenchyma, which displaced pancreatic tail and body to the right side with mild pressure effect on the stomach (figure 1).

A 67-year- old woman presented to our clinic with 5 years history of intermittent dysphasia. She described dysphasia during the intake of solid food and sometimes with liquid food. She did not note abdominal pain, hematemesis, or melena, but in the past two years, she noted a weight loss of 5 kgs. Her medical history was significant only for hypertension, which was controlled by 100 mg daily dose of metoprolol in divided doses. She occasionally took non-steroidal anti-inflammatory drug (NSAID). Physical examination did not reveal any finding.

This letter was written because of the high incidence of acute hepatitis A in our hospital in this period of time. In December 2016 and January 2017, eight patients with acute hepatitis A were admitted to Gastroenterology Ward of Imam Hospital. Some of them had acute liver failure and fulminant hepatitis.