فهرست مطالب علی مختاری فر

 Hemangioma is the most common benign liver tumor which is usually asymptomatic. There is no consensus on how to deal with symptomatic hemangiomas during pregnancy. In this report, a case of a symptomatic giant Cavernous Hemangioma in a 39-year-old woman at four month of pregnancy is introduced.
Case report:  A 39-year-old woman (Gravida4, para3) with a 4-month pregnancy was referred to the hospital due to pain in the epigastria and right hypochondria and nausea and vomiting. In clinical examination, a massive lesion which covered the entire upper abdominal region was palpable. Since it was symptomatic, it was successfully removed by surgery during pregnancy and Hemangioma with size of 23.5 x 16.5 cm was removed. Successful surgical removal of such a giant hemangioma is rare during pregnancy.

Epidermolysis bullosa is a group of acquired or inherited mechanobullous skin disorder, characterized by blister formation in response to physical traumas and hot weather. They differ according to severity, clinical feature, prognosis, histology and heredity pattern. Case report: Miss J is a 24 years old girl. She was admitted at Emam-Reza hospital, Mashhad University of Medical Sciences, Iran due to confusion, severe anemia, respiratory distress, sepsis, general weakness and generalized skin bullae. The skin bullae have appeared since the third day of her life. The patient looks like a severely pale small child. Her body weight was 24 kg and her physical growth was far less than her chronological age. Her skin biopsy was compatible with epidermolysis bullosa. Her general feature improved after administration of fluid, blood products and wide spectrum antibiotics. While the patients might have life threatening medical problems, physicians should be familiar with manifestations and treatment of rare and severe cases of epidermolysis bullosa.   Key word: Epidermolysis bullosa,Dystrophic type, Gastrointestinal

crohn disease(CD) is a disorder of uncertain etiology that is characterized by transmural inflammation of the gastrointestinal tract. CD may involved the entire gastrointestinal tract from mouth to the perianal area.
Case Report: Fifty years old man in with generalized edema, severe weakness, musculoskeletal disorder, scattered abdominal pain, dyspnea, psychotic state and pallor with history 20 years of crohn.
Physical examination: there were tachycardia, blood pressure= and general edema. In lab test anemia and hypo albuminia reported.
Imaging findings: In abdominal X-Ray in lie position the probability of the presence of air in right subdiphramatic area was reported ,which in chest X-Ray in lie position was not clear. In sonography and CT scan there was some fluid with local collection containing debrides which on aspiration pus collection was seen.
Laparatomy: copious pus collection with fibrin and adhesion without any fistulas or free perforation were observed.
penetration of the bowel most often present as an indolent process and not as acute of down part. For diagnosis of this complication, in addition to clinical manifestation use of all diagnostic methods is needed.

There are no data on familial aggregation of colorectal cancer (CRC) in northeastern Iran. The aim of this study was to determine the prevalence of early-onset CRC and patients suspected for hereditary non-polyposis colorectal cancer (HNPCC) based on the clinical criteria in this area.
Documents were collected from two hospitals in Mashhad regarding 326 inpatients during 2013-2015. Demographics, clinical, and tumor-related features were recorded. Interviews were done to identify cancer in the family up to second-degree relatives.
326 patients with CRC (48.5% male) were evaluated. The mean age at diagnosis was 55.44±14.85 years, with 91 patients (27.9%) below 45 years old. Eleven (3.4%) patients fulfilled the Amsterdam II criteria and 136 (41.7%) patients met at least one criterion of the revised Bethesda guideline. There was no difference between early- and late-onset CRC regarding the frequency of CRC in 1st degree relatives or tumor site (p=0.73, p =0.64). However, CRC in second-degree relatives and cases suspected for HNPCC were more common in early-onset of the disease (p =0.022, p =0.024). The patients who fulfilled the Amsterdam II criteria had lower mean age and higher frequency of proximal cancer (p =0.03, p =0.048).
As CRC is common in the young population and CRC clustering and patients suspected for HNPCC are also frequently encountered, measures should be taken to CRC screening policy and genetic studies in this area.

Hepatitis B and C infections have remained major global health burdens during the most recent century. The viral agents responsible for these diseases share common modes of transmission with human immunodeficiency virus (HIV) such as needle-sharing in IV drug abusers. Coinfection of hepatitis B or C with HIV increases the rate of progression of chronic liver disease. Given the lack of data in Iran, in particular Khorasan Razavi Province, with regards to this coinfection, the present study evaluates the frequency distribution of hepatitis B and C coinfection with HIV infection and their modes of transmission. This was a retrospective study based on available data at the Gastrointestinal and Liver Diseases Center, Emam Reza Hospital, Mashhad, Iran. We used questionnaires to collect demographic data from 749 patients infected with hepatitis B or C who refered to this clinic between 2005 and 2008. The available sera of these patients were tested for the coexistence of HIV infection with hepatitis B or C infections. The results were analyzed with SPSS version 16 software. From 749 patients infected with hepatitis B or C viruses, 650 were infected with hepatitis B (64.9% male and 35.1% female). There was no HIV antibody detected in any of the patients'' sera who had hepatitis B infection. Among the 106 patients with hepatitis C infection (84% male and 16% female), only one (0.9%) who was an IV drug abuser tested positive for HIV infection. Hepatitis B/hepatitis C coinfection was found in 7 (0.9%) patients. With regards to the risk factors of viral transmission among those with hepatitis B infection, the most common was a positive family history of hepatitis B (37.2%). Other risk factors in order of decreasing frequency included a history of venesection and tattooing (13.8%), transfusions (7.1%), IV drug abuse (2.6%), needle stick accidents (2.3%), and high-risk sexual activity (0.6%). In those with hepatitis C infection, a history of IV drug abuse was the most common risk factor (40.6%), followed by a history of transfusions (28.3%), venesection or tattooing (16%), surgery (13.2%), needle stick accidents (4.7%), hepatitis C infection in a family member (2.8%), and unsafe sexual contact (0.9%). There was a significant difference in the transmission risk factor ratio between hepatitis B and C patients (p=0.001, χ2=261/590) The most common risk factor for transmission of hepatitis B and C infections in patients who presented to Emam Reza Hospital, a referral center in Mashhad, was a positive family history of hepatitis B infection and IV drug abuse, respectively. The prevalence of HIV coinfection amongst patients with hepatitis B or C infections was low. However, further studies with larger populations are required.

Most patients with irritable bowel syndrome (IBS) do not respond to existing treatments. It seems that the pathogenesis is not fully understood. Trying to clear this condition، scientists have focused on the role of mast cells in the pathogenesis of IBS and many gastrointestinal disorders.

After taking history including demographic، clinical، familial and personal history of 57 patients with diarrhea-predominant IBS (criteria ROME III) colonoscopy done and in case of normal colonoscopy، samples of left and right colon were taken. Overall 48 samples could be retrieved. Immunohistochemical staining for mast cell tryptase was done and mast cells were counted. The prevalence of patients with mast cells > 20 / HPF was determined. The patients were divided into three categories: < 10/HPF، 10- 20 and > 20 / HPF and symptoms of three groups were compared. In addition to their traditional treatment regimen، all patients received Ranitidine and Cetrizine. Clinical responses were also compared in the three groups.

A total of 3 out of 48 patients (5. 8%) had >20 mast cells in each HPF (mastocytic enterocolitis). Distribution and severity of clinical symptoms of the patients in three groups were not significantly different. Respond to treatment with antihistamines was not significantly different in each of these groups of patients.

Mastocytic enterocolitis in our patients was not as frequent as other studies. Mast cells count was not associated with clinical symptoms.

A 46 years old gentleman was admitted to hospital following a 10 months history of sever diarrhea. On examination، the patient appeared as mildly dehydrated though his vital sings were within normal limits. important result tests were: Bun=55 mg/dl Na=149 mEq/dl WBC=11. 6*103/ml Hemoglobin=16. 2 g/d Cr=3 mg/dl K=3. 9 mEq/dl HCT=49. 7% Plt=324*103 Tbo/ul Neutr=74% After ten days administration of IV fluid، BUN and createnine gradually became normal (Cr=1. 1mg/dl، BUN=14mg/dl). There was no macroscopic or microscopic gastrointestinal pathology in upper and lower endoscopy. We took biopsies even from ileum terminal. We suspected endocrine tumors and pancreatic disorders، so we requested abdominal and pelvic CT scan (IV and oral contrast) and hormonal tests such as serum cortisole، metanephrin، normetanephrine، which were all normal. We therefore did an octrotide scan which was again normal. Because almost all organic etiologies of chronic diarrhea were excluded، we focused on neurological and psychological causes of chronic diarrhea. Therefore we consulted with neurologist & psychiatrist and they recommended brain CT scan and EEG which were normal. After complete interview، the psychiatrist diagnosed PTSD and depressive disorder NOS and prescribed imipramin 25mg/day. After 10 days the chronic diarrhea improved. As we excluded all the organic causes، we concluded likely the patient had IBS with PTSD and depressive disorder NOS.

Serum Carbohydrate Antigen, CA19-9, is a carbohydrate antigen whose usage -as a tumor marker- in pancreatic and bile ducts malignancies is commonly increasing. Sensitivity and specificity of this antigen in the diagnosis of malignancies is 70-90% and 68-91%, respectively. CA19-9 can also rise in other disorders and in few of benign conditions including cholangitis, due to other causes, e.g. choledocholithiasis. However, in such cases the increase is not significant and it is usually below 1000 u/ml. Values more than 10000 u/ml are limited to few case reports in articles. The case under study was a 66 year old man hospitalized because of epigastric and right upper quadrant pain, fever, jaundice, acholic stool, weight loss of about 6 kg, and hyperchromic urine. Physical examination revealed that the case was icteric and febrile with a mild RUQ tenderness on percussion. Laboratory tests showed marked elevation of bilirubin and CA19-9 (Total bilirubin: 36 mg/dl, Direct: 19.5 mg/dl; CA19-9: 44777u/ml, Normal: 0-40 u/ml), but the enzymes of the liver and alkaline phosphatase only increased to two times the normal level. Sonography showed dilated common bile duct with four stones within it. Four weeks after stones extraction and renewal of bile current CA19-9 fell to 60 u/ml and returned to normal range (0-40) 2 months later; and during this period the patient was totally asymptomatic. As a result, in patients with biliary obstruction, a diagnosis of malignancy cannot be made solely on the basis of increased concentration of CA19-9, even in case of high clinical suspicion and the interpretation of this increase must be done with more caution and after lab follow-up following removal of the obstruction.

IntroductionCoeliac disease (CD) is an autoimmune enteropathy triggered by gluten. Several hepatic disorders have been described in association with coeliac disease. Nodular regenerative hyperplasia (NRH) of the liver is a rare disorder and is a cause of non-cirrhotic portal hypertension.Case reportA 22 y/o lady presented with portal hypertension, after all causes of chronic liver disease ruled out we checked for coeliac and it was positive. Liver biopsy was done and was compatible with nodular regenerative hyperplasia (NRH) of the liver. ConclusionAs far as we know this is one of the rare cases of nodular regenerative hyperplasia of the liver in a patient with coeliac. Only three cases have been reported until now and seems we should think about coeliac in any patient suffering from chronic liver disease with unknown cause.

HBV infection is the most common cause of chronic hepatitis in Iran. HDV prevalence in chronic carriers of HBV has not been studied in the north-east of Iran. This study evaluated the prevalence, risk factors and co-infections of HDV with HCV.This cross-sectional study was carried out From Sep_ Oct 2004 to Sep_ Oct 2005. The patients divided into two groups, inactive chronic carrier and chronic liver disease (chronic hepatitis and/or liver cirrhosis). Our study included 350 chronic HBV carriers in whom we assessed HDV Ab by ELISA method, then HDV Ab positive patients were assessed for risk factors and Co-infections with HCV. Later risk factors and co-infections were compared in HDV positive and HDV negative patients. Analysis of serum markers indicated that 10% (35/350) of patients had evidence of HDV infection; Anti-HDV was found in 4.5% (7/153) of patients with inactive carriers, and in 14.2% (28/197) of patients with chronic liver disease (chronic hepatitis and/or cirrhosis). Main risk factors of HDV positive and HDV negative infections included positive family history, blood transfusion, which were almost equal in two groups (p> 0.5). One out of thirty five (2.8%) of HDV positive patients showed triple infection of HBV/HDV/HCV. Also, 2.8% (1/35) of HDV negative patients showed dual infection of HBV/HCV The present study shows that HDV infection is prevalent in the north-east of Iran, particularly in chronic hepatitis and cirrhosis, and it should be studied in them. Routine assessment of HCV in these patients is not recommended, unless risk factors exist.

Heartburn, which occure in 30-80 percents of pregnancies, have a vast injurious of social, emotional and environmental effects on the life of the pregnant woman as well as their society and occupation. Stressors such as tension of the job effect in contrast with housewives .This research has been accomplished in order to compare the occurrence and intensity of heartburn in employed and housewives pregnant woman
Material and This observational-analytical research was accomplished by applying cross-sectional and multi-stages sampling method on 310 pregnant housewives and 150 employed pregnant women who has necessary qualification and were referred to prenatal care centers in Bojnord. In three sections of three month of pregnancy ,used from interview form for determining the prevalence of heartburn in the last two months and used from interview form and visual index of Oklahoma for determining the intensity of heartburn. Our analysis of data were done with X2, T- student, Man-Withney, one way ANOVA, Log liner, Co-variance and by utilizing the SPSS software with 95% coefficient . Mean heartburn intensity were significantly different between two groups (P=0/0001 )and being more in employed women (Total of pregnancy, 5/23 ± 1/84 vs 4/2 ±1/66) (T1, 4/73±1/841/86 vs 3/88 ±1/21) (T2, 5/05± 1/97 vs 4/12 ±1/63) (T3, 5/75± 1/69 vs 4/13 ±1/64). The prevalence of heartburn in employed pregnant woman was more than that of housewives (T1: 21/8% vs 18/1% T2: 55/1% vs 44/3%, T3: 73/9% vs 61/8%, Total of pregnancy: 48/6% vs 42/6%). There was not significant relationship between the prevalence of heartburn and patient's occupation (T1, P=0/73) (T2, P=0/28) (T3, P=0/20) (Total of pregnancy, P=0/25). Employed pregnant women are at risk of heartburn in comparison with unemployed ones. It necessary to force and enhance suitable laws, specific education for better life method and better job qualification of employed women and more facilities to decrease their heartburn and unsuitable effect's one.

Helicobacter pylori treatment is advised in all cases of chronic dyspepsia recently but despite several new drugs, treatment failure is probable yet and the choice method to eradicate Hpylori is contraversial. We studied all patients with chronic dyspepsia who referred to endoscopic ward of Imam Reza hospital. After demonstration of Helicobacter pylori infection by rapid urea’s test (RUT), these cases were divided into two groups randomly. The first group was treated by Metronidazole, Amoxicillin and Omeprazole and the second group was treated by previous drugs plus Bismuth Substrate for 2 weeks. Then drug side effects were asked during the first and second week and Helicobacter pylori eradication was evaluated by UBT (Urea Breath test) six weeks after the treatment. Among 56 cases in this study 39.3% were male and 60.7% were female and 41-50 years cases were more frequent. 27 cases (48.2%) were treated by triple therapy and 29 patients (51.8%) were treated by quadruple therapy. Most common symptoms during the first week were abdominal pain and flatulence but during the second week the common side effect was flatulence. Although, treatment side effects were rare in the second week and only 25% of patients had significant symptom. Finally the total treatment success rate was 49% and Helicobacter pylori was eradicated according to UBT in 50% by triple therapy and 48% by quadruple therapy. The difference between two methods was not significant, although treatment success ratio was higher in young people. Triple therapy (Omeprazole, Amoxicillin and Metronidazole) is an effective regimen for the first line therapy in eradication of Helicobacter pylori especially in young people.

Huge splenomegaly has a large list of differential diagnosis (DDx) with infectious disease, Liver disease and cancers that we rolled out these DDx with step by step diagnosis. And finally we found hereditary Gucher’s disease, in spite of his age (49yrs). By the recurrent hemorrhage and severity of thrombocytopenia and leucopenia, spleenectomy was done and the patient discharged with good general appearance.Gaucher’s disease should be considered in the differential diagnosis of patients with unexplained organomegaly, easy bruisability and/or bone pain. Bone marrow examination usually reveals the presence of Gaucher cells; however all suspected diagnoses should be confirmed by demonstrating deficient acid b-glucosidase activity in isolated leucocytes or cultured fibroblasts.