ناصر ابراهیمی دریانی

Iatrogenic colonic perforation (ICP) is a rare but serious complication of colonoscopy, with an incidence ranging from 0.016% to 8% depending on the type and purpose of the procedure. Several patient-related, endoscopist-related, and procedure-related factors increase the risk of ICP, which most commonly occurs in the sigmoid colon. Following specific guidelines for colonoscopy performance and quality can help prevent ICP. Early diagnosis is essential, and imaging modalities such as radiography or CT scan may be needed to evaluate the extent of damage. The management of ICP depends on the size and location of the perforation, the presence of peritonitis or sepsis, the underlying colon pathology, and the patient's general condition. Endoscopic, surgical, or conservative methods may be used, but surgical consultation should always be sought urgently. Surgery is usually indicated for large perforations, signs of peritonitis, inadequate bowel preparation, severe comorbidity, failure of conservative treatment, underlying colon disease requiring surgery, transplant recipients, or immunocompromised patients. Laparoscopic-assisted exploration is the preferred surgical technique for ICP. The timing of a follow-up colonoscopy depends on the indication for the initial colonoscopy that led to ICP.

Nonalcoholic fatty liver disease (NAFLD) is defined by steatosis in more than 5% of liver cells, in the absence of a secondary cause such as drugs, alcohol, or other causes. The incidence of NAFLD is increasing every day; almost a quarter of the world's adult population is affected by this disease. The burden of NAFLD is affected by the epidemics of obesity and type 2 diabetes (T2DM), and therefore, we do not expect the prevalence of this disease to decrease in the future. The world is now in the process of passing on health to non-chronic diseases, like NAFLD. The most common cause of chronic liver disease worldwide is non-alcoholic fatty liver disease. About 25 percent of the world's population is affected by the disease, and it ranges from simple steatosis to cirrhosis. 1 in 4 individuals with NAFLD is a person with non-alcoholic steatohepatitis, which is associated with complications and significant mortality and morbidity due to complications such as liver cirrhosis and hepatocellular carcinoma. Non-alcoholic fatty liver disease is closely related to metabolic syndrome, and it can be said that the liver is an integral part of obesity. Diagnostic methods for this disease include laboratory tests, imaging studies and liver biopsy. Although NAFLD is observed predominantly in obese persons or type 2 diabetes, an estimated 7% to 20% of people with NAFLD have lean body habitus. Recent studies have shown that fatty liver can occur in lean individuals, even without abdominal and visceral fat. Fatty liver in lean people (Lean NAFLD) is a relatively new concept that has attracted many people to find the differences between lean and obese people. The pathophysiological mechanisms of lean NAFLD are still poorly understood. Studies have shown that NAFLD without obesity is more closely related to factors such as environmental, genetic susceptibility, and epigenetic regulation. In addition to lifestyle modifications such as weight loss, diet and physical activity, only a few NAFLD-specific drug treatment options such as vitamin E and pioglitazone are considered. This article discusses the pathogenesis of fatty liver in lean individuals, its treatment, prognosis, and its relationship with metabolic syndrome.

Although prescribing biological drugs have been common in Iran for nearly a decade and is now more widely available than ever, some physicians may still be unfamiliar with them. This guideline is the first joint statement of the Iranian Association of Gastroenterologists and Hepatologists (IAGH) regarding the proper use of biological drugs in IBD treatment. Many of the current guidelines are based on internationally published data due to a lack of national and regional information (individual and racial differences affecting patients' responses to biologics as well as characteristics). In this guide, we have tried to address various issues, including the indication for starting biological drugs, contraindications, prevention of complications, screening before starting biological treatment, and other follow-ups during treatment in Crohn's disease and ulcerative colitis. The authors of the article hope that based on these strategies, they will provide helpful information based on scientific evidence to physicians around the country to treat their patients with biological drugs successfully. As far as we know, this consensus on the starting and continuing of biologics is the first case to be compiled and published on the use of biological drugs in Iran, and it shows the importance of its application. However, the physicians’ decision about treating their patients is a priority. Naturally, it will be necessary to review the provisions of this agreement after the next 2-3 years.

Irritable bowel syndrome is a functional gastrointestinal disorder. Despite heavy economic and psychological burdens and severe decreases in quality of life of the patients, no certain cure is available for this common disease. Glutamine can decrease intestinal permeability and possibly improve intestinal barrier function and intestinal-friendly microbiota. Therefore, the aim of this study was to assess effects of glutamine supplementation against iso whey protein on clinical symptoms and quality of life of the patients with irritable bowel syndrome.

This study was a double-blind, randomized clinical trial; in which, 42 patients aged 18–70 years of the two sexes were participated for six weeks. Patients were randomized to receive glutamine (5 g, three times a day) or iso whey for six weeks. Scores of the irritable bowel syndrome symptom severity and quality of life scores were calculated at the beginning and end of the study.

Total severity score of the irritable bowel syndrome (p = 0.015), dissatisfaction with bowel habit (p = 0.001) and abdominal pain frequency (p = 0.028) significantly decreased in the glutamine group, compared to the iso whey group. Moreover, the total score of the irritable bowel syndrome symptom severity, abdominal pain frequency and  dissatisfaction with bowel habits respectively decreased by 180, 32 and 38 points, compared to the glutamine group at the beginning of the intervention.

Based on the findings, glutamine supplementation can be suggested as an adjunct therapy with a low FODMAP diet (oligosaccharides, disaccharides, monosaccharides and fermentable polyols) to further relieve symptoms of the patients with irritable bowel syndrome.

Gastrointestinal disorders are ranked first among medical disorders to seek psychiatric consultation. Various researches report multiple causes for and emphasize the role of psychological factors in causing or exacerbating symptoms of this disorder. Emotional distress highly affects people. Emotional regulation mechanisims are among the factors that could affect the level of emotional distress. The aim of this study was to investigate the predictive role emotional regulation on determining emotional distress in ipatients with psychosomatic and Functional Gastrointestinal disorder.

In this descriptive and correlational study, the population included 150 patients with FGIDs were selected by purposeful sampling method from indivisuals who referred to a specilalized clinic for Gastroenterology in Tehran. The participants completed Garnefski Cognitive Emotion Regulation Questionnaire :CERQ-36 )2006 ( and Depression Anxiety Stress Scale DASS-21 (1995). Data analysis was done in SPSS 24 using Pearson correlation coefficient and multiple regression.

Fndings showed a significant positive relationship between Maladaptive (negative) emotional regulation and emotional distress and its components (depression, anxiety, and stress). Also an indirect significant relationship was detected between Adaptive (positive) emotional regulation and two components of emotional distress in which adaptive emotional regulation signicantly predict depression and stress as two components of emotional distress .

Positive (adaptive) cognitive regulation Mechanisim play a role in decreasing the severity of emotional distress in individuals with Functional Gastrointestinal disorders/

Inflammatory bowel disease (IBD) is a chronic disorder that influences many aspects of a patient’s life. The medical treatment of the affected patient has been broadly investigated. Studies have shown that most physicians are familiar with treatment options, but they are not aware of proper preventive care for their patients. As most patients consider their gastroenterologists as their primary care provider, it is essential for gastroenterologists to inform the primary care providers of the unique needs of the patients with IBD, especially those receiving immunomodulators and biologics or are considered for such treatments. As most patients with are treated with long-term immune-suppressive drugs, and these drugs predispose the patients to many infectious diseases and cancers, it is important for primary care providers to document patients’ vaccination history comprehensively and screen for the cancers that these patients are encountered with, so that many of these disorders be prevented. Identification, safety, and proper timing of vaccinations, screening for cervical cancer, melanoma and non-melanoma skin cancers, osteoporosis, identification of depression and anxiety, smoking cessation, and care during traveling and flights are issues that will be discussed in this systemic review.

Hepatic cholestasis is characterized by elevated alkaline phosphatase and gama - glutamyl transpeptidase levels which is then followed by conjugated hyperbilirubinemia. It is classified into intrahepatic and extrahepatic cholestasis. Intrahepatic cholestasis indicates hepatocellular dysfunction or the presence of an obstructive lesion in intrahepatic bile ducts distal to biliary canalicular system. The first step in evaluating cholestasis is to distinguish intrahepatic from extrahepatic cholestasis. Abdominal sonography is a sensitive and specific modality to rule out intra- and extrahepatic biliary dilatation. If abnormal biliary tract is present, the next step is to perform Magnetic Resonance Cholangiopancreatography (MRCP) or Endoscopic Ultrasound (EUS). If there was not any evidence of biliary system obstruction in imaging, intrahepatic cholestasis is suggested and to evaluate this condition, initially Antimitochondrial antibody (AMA) should be checked and if the result was negative, liver biopsy should be considered.

Celiac disease is an autoimmune disorder that can occur in genetically predisposed people who ingested gluten. The most effective treatment for celiac disease is lifelong adherence to a strict gluten-free diet. Therefore, patients with celiac disease need to provide gluten free products. On the other hand, the price of these products are higher than normal ones. Therefore, the aim of this study was to compare the cost of gluten free products with similar regular non-gluten free products.

All available gluten free and similar regular products were collected during 2018 in Tehran, Iran and their prices and weights were calculated. The gluten free and similar regular products were divided into 13 categories and the items were calculated based on the weight and the prices were compared according to the same weights. The data were analyzed using SPSS software version 21.

A total of 128 products, 36 local and 28 imported gluten free product and 64 similar regular products food samples were collected and their prices were calculated in the same amounts of food. Overall, gluten free products were significantly more expensive than regular products. Most of the daily food requirements for patients with celiac disease were in average less than 5,000 Tomans. Only 19.11% of these gluten free products had an average price more than 30000 Tomans.

Considering the significant increase in the price of gluten-free products compared with gluten-rich products, the cost of food preparation for people with celiac disease in Iran is high, which can also affect the adherence to a gluten free diet.

The aim of this study was to develop a therapeutic plan based on hypnotherapy for patients with irritable bowel syndrome (IBS) and determine the effectiveness of this treatment on the intensity of IBS symptoms and rumination of patients with IBS.

The research design was a quasi-experimental with a pre-test, a post-test, and 3 months of follow-up. Of the patients who were referred to gastroenterology clinics in Tehran, 32 patients with IBS were randomly divided into two groups; hypnotherapy group and control group. Medical treatment along with hypnotherapy was individually conducted for eight sessions in the intervention group and the control group received only medical treatment. IBS Symptom Severity Scale (IBS-SSS) and rumination were completed in pretest, post-test, and follow-up stages by the patients and data were analyzed with repeated measures analysis of variance.

The variable scores of symptoms severity and rumination in experimental group was significantly lower than the control group (p > 0.05) and the effect of the therapeutic plan persisted until the follow-up stage.

The results showed that hypnotherapy can be an effective treatment for patients with irritable bowel syndrome. Therefore, psychological treatment is essential for the management of these patients.

Cytolethal distending toxin (CDT) is one of the bacterial toxins that present in a variety of Gram-negative human pathogens, such as E. coli, Salmonella spp. and Campylobacter spp. CDT consist of three subunits encoded by three adjacent genes, including cdtA, cdtB and cdtC. It is approved thet cdtB had toxic activity and caused DNA damage of the host cell. Despite its presence in different bacterial species, role of CDT in acute and chronic infections, such as gastroenteritis and irritable bowel syndrome (IBS) is unclear. To clear this correlation, we studied the prevalence of cdtB gene among different enteropathogenic bacteria in patients with gastroenteritis and IBS compared with healthy people. This study was conducted on stool samples that obtained from patients with gastroenteritis, IBS and healthy people (as control). All the samples were subjected to DNA extraction. cdtB of Campylobacter spp., Yersinia entercolitica, Providencia alkalifacience, Salmonella enterica and E. coli was analyzed by PCR using specific primers. CdtB encoding Campylobacter spp. was found in 7.5% (5/80) and 34.6% (52/150) of patients with IBS and gastroenteritis, respectively. Also, the PCR results showed that 14% (14/150) of the patients with gastroenteritis and 5% (8/80) of IBS patients carried CdtB encoding Salmonellaenterica. None of the samples were infected with CdtB -encoding E. coli and Providensia spp. Finally, all results were confirmed by sequencing. Our results showed the presence of CdtB encoding pathogenic bacteria in IBS patients and those with gastroenteritis. Regarding the high frequency of CdtB encoding Salmonella and Campylobacterspp., it was proposed that infection to these bacterias could be considered as a risk factor for the development of post-infectious IBS in Iranian patients. Further studies are needed to establish this relationship.

A 40-year-old woman was referred to our health center with a bulky rectorrhagia. The patient was treated with meropenem and vancomycin for an enterococcal meningitis one week earlier. A colonoscopy was performed at a different center, which was unsuccessful due to high blood volume in the colon and poor vision. The patient underwent angiography of the superior and inferior mesenteric arteries and the rectum artery, but the origin of the bleeding was not known. A polypoid mass with ulcer and bleeding from the site was seen in repeated colonoscopy of the left colon reagion. Due to the severity of the bleeding, the patient was transferred to the operating room and a large uterine mass that had transmitted to the lobes of the sigmoid colon was observed. Due to the diagnosis of uterine tumor, hysterectomy and oophorectomy were performed, and the descending colon was removed as a colostomy from the abdominal wall. In the pathological examination, diffuse endometriosis was found, which had involved the left ovary, the left fallopian tube, and both parametrium and sigmoid to the submucosal layer. On the 26th day, the patient was discharged with a good general condition and full vigilance.

Clostridium difficile infection in patients with inflammatory bowel disease (IBD) is associated with more severe disease, longer hospital admission, higher treatment costs, higher risk of colectomy, and higher mortality rate. The classic endoscopic view of the disease is adherent whitish-yellowish multifocal membrane, defined as “psudo-membrane”. Using stool polymerase chain reaction (PCR) is the best way for identifying this organism. Patients with mild to moderate infection are treated with oral metronidazole, while severe infections are treated with oral vancomycin for 10 days. The first recurrence of clostridium infection is treated with the same regimen as the initial episode, however the second recurrence is treated with vancomycin pulse therapy. In the third recurrence, fecal microbial transplantation (FMT) is one of the treatment choices. This study is a report of three successful FMT in our patients.

Upper gastrointestinal bleeding (UGIB) is usually a medical emergency which needs appropriate medical and endoscopic treatment. The incidence of this disorder is between 48 to 180 patients in each 100,000 adult per year in USA. Although medical and endoscopic treatment has been improved recently but the mortality rate of this disorder has not significantly changed, and the mortality rate is about 5%-10%.The prevalence of UGIB is growing regarding to increase in patients age and comorbid illnesses such as cardiovascular and renal disease. The other etiology is increase in use of drugs like NSAID and aspirin. Proper evaluation and treatment of patients with UGIB is necessary to improve the outcome of patients. In this study we review the initial approach and treatment of patients with overt UGIB.

There is evidence suggesting a relationship between flaxseed and NAFLD risk factor management including obesity, insulin resistance and diabetes. The objective of present study was to evaluate the effects of supplementation with Flaxseed on liver enzymes, hepatic fibrosis and steatosis in patients with NAFLD.

A two-arm randomized controlled clinical trial was conducted on 50 patients with NAFLD. The participants were assigned into a lifestyle modification (LM) on the NIH guidelines, or LM + 30 g/d brown milled Flaxseed for 12 weeks. Liver enzymes and hepatic fibrosis and steatosis were assessed at the baseline and at the end of the study. In addition, data were collected on anthropometric measurements and physical activity. The SPSS 20th version was used for data analysis.

Among the 50 volunteers, 24 in the treatment group and 22 in the control group completed the study. At the baseline, no significant differences were seen in the background variables between the two groups. After 12 weeks, flaxseed supplementation was associated with a significantly greater reduction in the liver enzymes of alanin aminotransferase, aspartate aminotransferase and &gamma-glutamyltransferas (P < 0.05). The mean reduction in fibrosis score in the flaxseed group was significantly greater than in the control group (-1.26 vs. -0.78 P = 0.03), similarly as steatosis score (-47 vs. -15.47 P = 0.04).

On the basis of the findings, it can be concluded that flaxseed supplementation can act as a new therapeutic approach in NAFLD management.

Dyssynergic defecation disorder (DD) has recognized as the main factor for chronic functional constipation. This was a debilitating disease effective on diverse aspects of physical, psychological and social functions as well as patients’ quality of life generally. Modern studies show positive impact of biofeedback therapy on dyssynergic defecation. This study was evaluated the efficacy of biofeedback on quality of life in patients with dyssynergic defecation.A total of 30 patients with dyssynergic defecation disorder visited tertiary care centers who were selected. Among them, 15 subjects underwent 8 biofeedback therapy sessions as experimental group and remaining subjects were placed into control group without biofeedback intervention. Both groups participated in pre-test and post-test of 36-item short form survey (SF-36) of quality of life. Data were analyzed and compared by analysis of covariance (ANCOVA).Findings shows that biofeedback therapy was effective on quality of life patients with dyssynergic defecation (p= 0.001) Also, index effect suggested that 53% increased of QOL patients with dyssynergic defecation in experimental group can be related to biofeedback therapy. Also in 8 cases, results indicated that biofeedback therapy was effect on quality of life in patients with DD (p<0.05).Given the results in this study, biofeedback is a long-term effective method to treat with limited side effects in dyssynergic defecation and patients QOL.

Ulcerative colitis (UC) is an inflammatory bowel disease in which immune and inflammatory factors are thought to be a factor. Resveratrol is an antioxidant and anti-inflammatory compound. This study determined the effects of resveratrol compound on inflammatory factors in patients with ulcerative colitis. This study was a double-blind randomized clinical trial conducted on 50 patients with UC. Subjects received one capsule daily for 6 wk of either resveratrol (500 mg) or a placebo. Inflammatory factors, anthropometric measures, and IBDQ-9 scores were assessed at baseline and at the end of the study. STATA12 software was used for data analysis. No significant differences were found in the background variables between the two groups at baseline. The results indicated that resveratrol supplementation for 6 wk significantly decreased plasma levels of TNF-a and hs-CRP and the activity of NF-κB over the placebo group (p < 0.001). Significant differences remained after adjustment for vitamin C (p < 0.0001). The IBDQ-9 scores increased significantly in the resveratrol group over the placebo group (p < 0.001). The findings of this study showed that resveratrol supplementation can be useful in patients with ulcerative colitis.

Nonalcoholic Fatty Liver Disease (NAFLD) is one of the most wide-spread human diseases that can impair liver function and sometimes progresses to cir-rhosis. Recently NAFLD has been identified as an independent risk factor for cardio-vascular disease. The aim of this study was to investigate the correlation of fatty liver disease and its sonographic severity on the resistance of the intracranial arteries. This study was a cross-sectional study of 55 patients referred from Gastroen-trology clinic with diagnosis of NAFLD to Sonodoppler department of Iranian Center of Neurological Research. Pulsaltile index as a Hemodynamic parameter of Middle Cerebral (MCA) and basilar Arteries of NAFLD Patients was measured by Trans Cra-nial Doppler (TCD) sonography and the measurements were compared with normal values. Also the association of these indices with serum liver enzymes and sonographic grading of liver involvement was assessed. The analysis was done by SPSS 16. Fre-quency distribution, mean and standard deviation were used in descriptive analysis and statistical test 2 to compare qualitative variables. Pulsatile Index (PI) were normal (MCA, P= 0.166, Basilar, P= 0.053) and there was no significant difference with relation to severity of fatty liver based on so-nography findings (P= 0.789), but serum liver enzyme levels were inversely correlated with basilar artery PI (P= 0.014). Considering the increase of cerebral arteries PI in advanced liver disease, absence of increase in vascular PI of patients in the present study could be attributed to the short duration of disease from diagnosis to perform TCD, lack of advanced liver involvement (absence of liver dysfunction) and the response effect to treatment before the TCD. Therefore, to assess vascular changes over time, repeating the TCD with assess other parameters such as Fibroscan and K18 factor that has more compatibility of liver function, could help to understand the pathophysiology of liver diseases and its effect on vascular resistance.

Sexual dysfunction is common in chronic diseases such as irritable bowel syndrome (IBS). Sexual function is an important aspect of quality of life. The present study seeks to determine the relationship between sexual function and quality of life in patients with IBS. Materials and Methods L:In this cross-sectional study, 47 female patients with IBS who referred to the one of gastroenterologist clinics in Tehran and gastroenterologist clinic at Imam Khomeini Hospital, selected via the available sampling method. Patients completed the Irritable Bowel Syndrome Quality Of Life questionnaire (IBS-QOL) and Female Sexual Function Index (FSFI). Data were analyzed by Pearson correlation models. According to the IBS-QOL, patient's mean score for quality of life(121.9) was poor. The FSFI mean score was indicative of sexual dysfunction. We observed a significant correlation between sexual function and quality of life in patients with IBS (p<0.05). There was a significant correlation between dyspareunia and quality of life in patients with IBS (p<0.05). This study showed the presence of a relationship between sexual function and quality of life in patients with IBS. Therefore appropriate strategies for education and counseling should be adopted, as well as referral to a psychologist or psychiatrist for sexual health promotion to improve the quality of life in patients with IBS.