ramin niknam

Nearly four years after the COVID-19 outbreak, its burden persists, with long-term physical and mental impacts still being discovered.

Given that these effects may vary across different periods post-infection and in diverse cultural, medical, and economic settings, we aimed to evaluate the health-related quality of life (HRQoL) in Iranian patients six months after acute infection.

A total of 194 infected patients were enrolled and re-evaluated six months after the onset of acute infection. Health-related quality of life was assessed using the validated EQ-5D-3L questionnaire.

The mean age of patients was 50.1 ± 15.8 years, with a female-to-male ratio of 1.04. Diabetes mellitus and hypertension were the most common comorbidities. Significant impairment was observed in all categories of HRQoL after recovery from acute COVID-19 infection (P-value < 0.05). Female gender, older age, and intensive care unit admissions were independent factors associated with worsened health status post-recovery. The overall reduction in post-COVID-19 infection quality of life (QoL) score was 25%.

The mental and physical burden of COVID-19 in our study population was considerable. Comorbid conditions and a lack of supportive measures post-infection, especially in a low-income country, may contribute to the long-term effects of COVID-19.

Ascitic fluid infection (AFI) is the most common bacterial infection in patients with cirrhosis and has several variants, including spontaneous bacterial peritonitis (SBP), bacterascites (BA), and culture-negative neutrocytic ascites (CNNA).

To date, there has been disagreement about the differences in clinical features and outcomes of these variants of AFI, and there are still few studies in this area.

A cross-sectional study was conducted at a referral hospital from June 2018 to September 2022. All cirrhotic patients with ascites were evaluated for the presence of AFI. Patients with AFI were divided into SBP, BA, and CNNA variants. Non-AFI participants were also evaluated as a comparison group. The outcomes, as well as the clinical and laboratory characteristics of the variants of AFI, were compared. Kaplan-Meier curves and Cox regression analysis were used for survival analysis.

A total of 466 patients were studied, of which 132 (28.33%) were in the AFI group and 334 (71.67%) were in the non-AFI group. In the AFI group, 64 (48.48%) had SBP, 43 (32.58%) had CNNA, and 25 (18.94%) had BA. The most common bacteria causing AFI was Escherichia coli . SBP (HR 2.43; 95% CI 1.36 - 4.36; P = 0.003) significantly increased the risk of mortality, while CNNA and BA did not significantly increase this risk. The presence of hepatic encephalopathy and female gender also significantly increased the risk of mortality.

The mortality risk was higher in patients with SBP compared to other types of AFI. This study also showed differences in clinical characteristics and laboratory parameters among the three types of AFI. Further research is recommended.

Until now, there has been disagreement regarding the prevalence, causes, predisposing factors, and outcome of ACLF (Acute-on-chronic liver failure). As a result, we have undertaken this research study.

ACLF is a complex syndrome with a poor prognosis.

In this cross-sectional study, we evaluated the prevalence, causes, predisposing factors, and outcomes of adult cirrhotic patients with ACLF and acute decompensation (AD). ACLF was defined based on the criteria established by APASL (Asian Pacific Association for the Study of the Liver). The severity of organ failure was assessed using both EASL-CLIF (European Association for the Study of the Liver- Chronic Liver Failure) and NACSELD (North American Consortium for the Study of End-Stage Liver Disease) scores. To investigate the impact of different independent variables on mortality, survival analysis methods were used.

A total of 156 patients' data were analyzed in this study. The mean age of patients with ACLF (56.62±16.19 years) was significantly lower compared to the AD group (62.30±14.28 years). Nonalcoholic steatohepatitis and infection were the most common causes and predisposing factors in both AD and ACLF groups, respectively, but the difference between the two groups was not statistically significant. The most common organ failures observed were hepatic encephalopathy and respiratory failure. The probability of death at any given time for was significantly higher in ACLF patients than in the AD group (log rank test; P<0.001). The results of Cox regression analysis revealed that low blood pressure (HR 0.97; 95% CI 0.96-0.99; P<0.001) and decreased blood pH (HR 0.53; 95% CI 0.28-0.99; P=0.04) were significant risk factors associated with increased mortality.

ACLF patients had a lower average age and higher mortality rates compared to AD. Nonalcoholic steatohepatitis was found to be the most common underlying disease in ACLF patients, while infections were identified as the predominant predisposing factor. All cases of mortality in the ACLF group were categorized as grade 3 and 4 based on the EASL-CLIF severity score. Hemodynamic instability and metabolic acidosis emerged as the most significant risk factors associated with increased mortality.

With Currently, Endoscopic retrograde cholangiopancreatography (ERCP) has evolved as a therapeutic intervention for treating disorders related to the biliary system and plays an important role in treating benign and malignant strictures of the biliary system.
The placement of biliary stents is a frequent and useful procedure to decompress the biliary system, and endoscopic biliary stenting seems relatively simple. However, in some cases, it can lead to several complications. Distal or proximal migration of endoscopically placed biliary stents is one of the known complications of ERCP and can affect up to 6-10% of patients.
Several factors, including those related to the patient, endoscopy, or stent, are involved in stent migration. When migration occurs, it is necessary to remove or replace endoprosthesis to prevent recurrent biliary complications and more severe consequences such as cholangitis and sepsis.
This review explores the frequency, etiology, risk factors, complications, and management strategies pertaining to biliary stent migration, consolidating diverse management approaches for informed decision-making.

Hepatitis A is a widespread viral infection with significant public health implications. Assessing glucose 6-phosphate dehydrogenase (G6PD) deficiency in hepatitis A patients is essential for various reasons, including prognosis, disease severity evaluation, encephalopathy risk identification, tailored management, and advancing scientific understanding. This study aimed to investigate the prevalence and clinical implications of G6PD impairment in individuals with fulminant hepatitis A.

A cross-sectional descriptive analysis was conducted, involving hospitalized patients with fulminant hepatitis A. Demographic data, prevalence rates, and clinical findings were recorded in a database. The diagnosis of hepatitis A infection was confirmed using an anti-HAV IgM antibody test, and G6PD enzyme activity was measured with a fluorescent spot assay.

Out of 81 patients with hepatitis A, 57 (70.4%) were males, and 24 (29.5%) were females, with an average age of 24.6 years. Dark yellow urine and anorexia were the most common clinical symptoms. Notably, 30 (37%) patients lacked G6PD. The group with G6PD deficiency showed significantly higher rates of encephalopathy and mortality (P<0.01), along with elevated bilirubin (P=0.00), abnormal coagulation parameters, and low hemoglobin levels (P=0.00).

In light of these findings, the present study proposes the implementation of routine G6PD level assessments and the evaluation of other relevant markers in regions where hepatitis A is endemic. Furthermore, the study underscores the need for vigilant monitoring of hemolysis and encephalopathy in affected patients to optimize clinical management and reduce morbidity and mortality associated with this condition.

There are few reports evaluating different factors, including the severity of duodenal histopathological findings and serological levels of celiac disease (CD), in increasing the probability of thyroid diseases (TD) in adults and children with CD, so, we designed this research.

CD was defined as Marsh type 2 or higher in duodenal histopathology and serological levels of anti-transglutaminase antibodies (anti-tTG) equal to or greater than 18 IU/ml. To assess the likelihood of TD in CD patients, logistic regression analysis was employed.

538 patients were included in this study. Of these, 354 (65.8%) were females and 184 (34.2%) were males. 370 (68.8%) patients were children. Overall, 57 (10.6%) patients had TD, of which 49 (9.1%) had hypothyroidism and 8 (1.5%) had hyperthyroidism. Adults had a significantly higher probability of developing TD than children (OR 1.9; 95% CI 1.1-3.4; P = 0.03). The odds of developing TD were also significantly higher in patients with family marriage in parents (OR 2.3; 95% CI 1.1-4.7; P = 0.03). Other variables such as gastrointestinal symptoms, anti-tTG levels, and severity of Marsh classification did not exhibit a substantial rise in the likelihood of TD development.

The study findings indicated that the likelihood of developing TD in CD patients can be linked to advancing age and having family marriage in parents, while there was no significant association observed with anti-tTG levels, severity of histological damage, and gastrointestinal symptoms.

Metabolic syndrome (MetS) is a set of conditions that occur together and increase the risk of cardiovascular disease. Previous studies have linked a gluten-free diet (GFD) to obesity and MetS in some populations. However, others have suggested that weight gain is usually regulated only in underweight individuals with celiac disease (CD). Owing to the lack of sufficient data and the importance of GFD in controlling cardiovascular disease, we surveyed the prevalence of MetS and its components before and after a year of GFD in patients referred to the main celiac clinic in southern Iran.

This was a repeated cross-sectional study conducted on 69 patients with a definite diagnosis of cardiovascular disease who were on follow-up and registered at the Shiraz Celiac Clinic. Demographic, anthropometric, and laboratory measurements at the time of diagnosis and one year after the GFD were extracted from their medical records.

The participants’ mean age was 35.53, and 68.1% were women. The prevalence of MetS increased from 5.8% to 11.6% after a year of the GFD; however, this increase was not statistically significant. Waist circumference (WC) and serum triglyceride levels were significantly elevated during the study period.

A GFD may contribute to the development of MetS in patients with cardiovascular disease; however, the rate of MetS is still lower than that in the general population. It is critical to educate patients about these potential risks and encourage them to have a healthy lifestyle that includes a balanced diet and physical activity.

Health-related quality of life (HRQOL) assessment in patients with celiac disease (CD) leads to understanding the impact of the CD and interventions on the individual and society. The aim of this study was transcultural adaptation and evaluation of the reliability and validity of the standardized questionnaire of celiac disease quality of life (CD-QOL) in the Persian language in southwest Iran.

150 adults with CD were randomly selected from the celiac clinic and Fars Celiac Registry to complete the New Persian version of the CD-QOL questionnaire. Transcultural adaptation of the questionnaire was conducted by a four-step procedure. The internal consistency of the CD-QOL subscales and convergent and discriminant validity were assessed using Cronbach’s alpha coefficient and Spearman’s correlation, respectively. Construct validity was evaluated by exploratory and confirmatory factor analysis.

All domains of the CD-QOL questionnaire had acceptable internal consistency, showing excellent reliability. The scaling success rates for convergent and discriminant validity were also within an acceptable range (87-100%). In the factor analysis model, similar to the original English version, four factors were extracted characterizing the patients’ answers (limitations, dysphoria, health concerns, and inadequate treatment).

Our Persian version of the CD-QOL questionnaire had high reliability and validity and could be used in clinical practice assessing the CD-specific HRQOL in the Iranian population.

Despite the importance of a gluten-free diet (GFD) in the management of celiac disease (CD), non-adherence is quite common and varies in different societies. The aim of this study was to survey adherence to a GFD and identify the barriers in the adult celiac population in Shiraz.

In this cross-sectional study, the patients diagnosed with CD were determined through serum levels of tissue transglutaminase IgA (tTg-IgA) and immunoglobulin A (IgA). In patients with positive anti-tTG, small bowel biopsies were taken. A gastroenterologist routinely assesses CD patients at Shiraz Celiac Clinic. Also, an expert general practitioner describes a list of forbidden food to patients. Adherence to a gluten-free diet was evaluated using interview and tTg-IgA level.

Adherence to a gluten-free diet was 58.2% among 170 participating patients aged 15 to 71 years. There was no significant difference in sex (P=0.730), current age, and age at the time of diagnosis (P>0.05) between the adherent and non-adherent groups. However, the adherence among the unemployed (P=0.036) and highly educated ones was significantly higher than others. More patients adhered to the gluten-free diet for 1-3 years (63.7%), so after three years, less adherence was seen (50%). The most reason for non-adherence was lack of proper access and labeling, cost, and feeling different from others.

Advances in the catering/food industry, increasing economic support and awareness about CD, GFD, and gluten-free products, as well as removing barriers such as inaccessibility and cost, can improve adherence to a GFD.

Routine bowel preparation instructions are usually given to patients in the form of oral explanations with written instructions. The purpose of this study was to evaluate the effectiveness of multimedia training in the form of video CDs on the quality of colon preparation and other related indicators.

201 outpatients in three referral academic colonoscopy centers were randomly assigned to two groups. The first group (n = 100) received supplementary video CD education besides the routine instructions (VCD group). The second group (n = 101) received only routine instruction, which included oral and printed instructions (non-VCD group).

Complete use of colon cleansing medication was statistically and significantly better in the VCD group (P = 0.038). Duration of colonoscopy was shorter in the VCD group (P = 0.001), demand for conscious sedation was lesser in the VCD group (P = 0.049), and the quality of colon preparation was better in the VCD group (P < 0.00). There was no statistically significant difference in pain sensation (P = 0.1), cecal intubation rate (P = 0.3), and technical difficulty of the colonoscopy (P = 0.1) in both groups.

Supplementary education in the form of multimedia CD increases the patients’ compliance to cleansing mediation consumption, improves the quality of bowel preparation, and decreases the duration of colonoscopy with lesser demands for conscious sedation.

The purpose of this study was to determine the cases of complaints of medical malpractice in gastroenterology referred to Fars Forensic Medicine from 2005 to 2020.

In a descriptive and retrospective study, the cases of adult gastroenterology medical malpractice cases referred to the specialized commissions of Forensic Medicine in Fars province from 2005 to 2020 were examined. The data were expressed in the form of descriptive statistics. Chi-square test was used to compare the frequency between groups.

The frequency of claims against the field of gastroenterology had increased more than 6 times in the second five-years of review. In terms of the health status of the plaintiffs, 56 patients (64.36%) died, 4 patients (4.59%) were disabled, 10 patients (11.49%) were recovering, and 8 patients (10. 30%) were improved.

This study showed that during the studied years, the frequency of complaints from the specialized field of adult gastroenterology has gradually increased.

Celiac disease (CD) is a common autoimmune disorder that presents intestinal and extra-intestinal symptoms. It is also associated with cardiovascular diseases and malignancies, and mortality risk. The only way to control the disease is to follow a strict gluten-free diet (GFD) for the rest of life.

This survey aimed to investigate GFD non-adherence and causes in the pediatric setting.

In this study, 187 children aged between 2.5 to 14 years old with a confirmed diagnosis of CD at least for a year were studied using a questionnaire-based interview in a census study between 2018 to 2019 in a referral center in southern Iran.

About 40% of children adhered to a GFD poorly. This group significantly complained of more symptoms than the group with high adherence. Improper access was the most important cause of non-adherence to a GFD. The mean current weight and at the time of diagnosis as well as the mean current BMI and at the time of diagnosis in the non-adherent group were significantly lower than the adherent group. However, IgA anti-transglutaminase antibodies and histopathologic examination did not change remarkably. Furthermore, no significant relationship was found between following a GFD and age, age at the time of diagnosis, gender, and parental educational status.

According to our results, inaccessibility, high costs, and lack of food labeling were the primary reasons for non-adherence to GDF. Therefore, to increase compliance, easy access to GFD with proper food labeling and suitable price should be implemented.

Upper gastrointestinal (GI) bleeding is a common cause for Emergency Department and hospital admissions and has significant mortality and morbidity if it remains untreated. Upper endoscopy is the key procedure for both diagnosis and treatment of acute upper GI bleeding. The aim of this article is to review the optimal timing of endoscopy in patients with acute upper GI bleeding. The cost-effectiveness and the influence of urgent or emergent endoscopy on patients’ outcomes are discussed. Also, we compare and contrast the available evidence and guidelines regarding the recommended time points for performing endoscopy in different clinical settings.

Celiac disease is a common disorder but there are few studies comparing the clinical features of the disease in adults, adolescents and children.

Demographic and clinical characteristics of all patients with celiac disease referred to the Celiac Clinic were evaluated and compared in different age groups.

Of 3416 participants, 473 patients were included. 302 (63.8%) were women and 171 (36.2%) were men. Overall, 325 (68.7%) and 411 (86.9%) patients had gastrointestinal (GI) and non-GI manifestations, respectively. The most common symptom in adults was psychiatric problems (66.5%), while abdominal discomfort was the most common symptom in adolescents (45.2%) and children (53.8%). According to age groups, GI manifestations were seen in 79 (66.4%), 119 (59.8%), and 127 (81.9%) children, adolescents, and adults, respectively. Adults had significantly more GI manifestations than the other groups (PR 1.167; 95% CI: 1.094- 1.244; p < 0.001). Non-GI manifestations were seen in 90 (75.6%), 174 (87.4%), and 147 (94.8%) children, adolescents, and adults, respectively. Adults had significantly more non-GI manifestations than the other groups (PR 1.112; 95% CI: 1.060-1.168; p < 0.001).

Our study showed that there were significant differences in the clinical features of celiac disease between the different age groups. Considering these results may help plan for future studies.

Hepatitis C is one of the most common causes of end-stage liver disease and liver transplant worldwide. In recent years, with the rapid advances in the treatment of hepatitis C by direct-acting antiviral drugs (DAAs), the clinical course of the disease as well as liver transplantation have had significant improvement. Also, DAAs have completely replaced interferon-based regimens in the treatment and prevention of HCV recurrence after liver transplant.

This is the first study that aimed to investigate the clinical course of liver transplantation in patients with hepatitis C in Iran.

This retrospective study was conducted on patients with HCV liver transplantation within five years (2012 - 2017) with the age range of 18 to 65 years at Shiraz Organ Transplant Center. All demographic and clinical data were recorded. Pre-transplant viral load, disease recurrence, graft rejection, and mortality rate were the most important indices in this study.

Among 55 transplant patients, 49% had received hepatitis C treatment before liver transplantation and interferon-based regimens were more prevalent. Besides, HCV genotype 3, followed by genotype 1, was the most prevalent one. A liver biopsy was performed in patients with elevated liver enzyme levels. The numbers of patients with HCV recurrence at 2, 6, 12, and 24-month intervals were three, two, zero, and two patients, respectively. At these time intervals, eight, eight, one, and three cases of acute graft rejection were found, respectively. Eight patients died with a one-year survival rate of 85%. Sepsis and infectious complications were the most leading causes of death.

This study is the first study of liver transplant patients with hepatitis C in Iran. In the five-year study period, rapid development was made in the treatment of HCV patients. It led to the introduction of DAAs, which replaced interferon-based therapies. The results of this study indicated the high success rate of liver transplantation in patients with hepatitis C in Iran. The results of this study could be used to compare the efficacy of DAAs in future research.

This study investigated the safety and efficacy of tenofovir disoproxil fumarate (TDF) compared with lamivudine (LAM) in the prevention of recurrent HBV infection after liver transplantation (LT).

Although the recurrence of hepatitis B virus after liver transplantation (LT) is now very uncommon with both nucleoside and nucleotide analogs represented with lamivudine and tenofovir disoproxil fumarate, respectively, few studies have compared the two classes.

A total of 302 HBV-related post-transplant patients who received liver transplants from deceased donors were enrolled in this retrospective study from 2011 to 2015 in the Shiraz Organ Transplant Center, Iran. The demographic data, kidney function, recurrence, resistance rate, and acute rejections at 1-, 6-, and 12-month intervals and after 12 months were compared on TDF (n=209) and lamivudine (n=93) groups.

During a median follow-up period of 42.9 months, mean creatinine level was not significantly different between the two groups. Hepatitis B virus recurrence rate as well as acute graft rejection episode had no statistical difference in either group over the study period.

Kidney function, creatinine level, disease recurrence, and acute graft rejection were comparable between tenofovir disoproxil fumarate and lamivudine in patients who received follow-up periods.

Celiac disease (CD) is a common disease caused by autoimmunity to the gluten protein. Although some studies have shown an association between infertility and abortion with CD, there are many risk factors that may influence this relationship that should be addressed in the researches. Therefore, we designed this study to evaluate this association with respect to these confounding factors.

This study was designed to investigate the association between infertility and abortion with CD in women who were referred to the celiac clinic in Fars province, from October 2017 to April 2020. CD was defined as an increase in serum levels of tissue transglutaminase antibodies and histological confirmation of a small bowel specimen, infertility with no pregnancy after 12 months of unprotected sex, and abortion with spontaneous termination of pregnancy before the 20th week.

Out of 711 patients, 98 women with CD were eligible for inclusion. The mean age (SD) was 31.73 (7.52) ranging from 19 to 45 years. 27 (27.6%) and 39 (39.8%) patients had a history of infertility and abortion, respectively. According to Robust Poisson regression models, weight loss with a body mass index of less than 18.5 kg/m2 was significantly associated with infertility (PR=0.779, CI95%=0.640-0.950, P=0.013) and abortion (PR=0.794, CI95%=0.649-0.971, P=0.025), but other variables such as age, ethnicity, education level, gastrointestinal manifestations, tissue transglutaminase antibody level, histological severity, family history of CD, and history of cousin marriage were not significantly associated with infertility or abortion.

In this study, weight loss due to long-term malnutrition was suggested as an important risk factor for fertility problems in CD. There was no significant association between infertility and abortion with other variables such as the level of anti-transglutaminase antibody and histological findings. Therefore, routine use of antibody levels and evaluation of the severity of histological findings as criteria for predicting the risk of abortion or infertility in these patients is not recommended until further research is performed.

Leiomyosarcoma of vascular origin is a rare malignant tumor. Inferior vena cava (IVC) is the most common site of vascular leiomyosarcomas. Leiomyosarcoma of IVC is predominantly seen in middle-aged women presenting with non-specific symptoms and clinical findings. Herein, we report a case of leiomyosarcoma of IVC in a 44-year-old woman presented with progressive abdominal discomfort and postprandial vomiting. Laboratory results were in favor of acute liver injury. Imagings revealed a retroperitoneal mass and enhancement in almost the total course of inferior vena cava with extension into both renal veins and right atrium. Histopathological examination showed a malignant spindle cell tumor and immunohistochemistry confirmed smooth muscle origin of the tumor.

Self‑medication is common among patients with gastrointestinal (GI) symptoms. This study was performed to evaluate self‑medication among patients who fulfilled irritable bowel syndrome (IBS) and dyspepsia diagnostic criteria and to investigate the appropriateness of self‑medication with chemical and herbal drugs.

Aprospective, descriptive cross‑sectional study was conducted in outpatient’s GI clinics at Shiraz from November 2011 to May 2012. A GI specialist visited the patients and recruited those who had IBS (base on Rome III adapted criteria) or functional dyspepsia. We surveyed self‑medication among these patients, using a questionnaire containing specific questions about self‑medication.

One thousand four hundred and forty‑seven patients visited by the GI specialist during the study period. Seven hundred and forty‑seven patients had the inclusion criteria, 337 of them fulfilled criteria for IBS, with IBS‑mixed (52%) being the most prevalent subtype, and 410 patients had dyspepsia. Overall, 78.8% of the total participants had recently sought medical attention for their GI complaint. Twenty‑eight percent of patients selected inappropriate medication for their GI complaints. The H2‑blockers class were most common medicines reportedly used. We did not find any significant relationship between age, gender, level of education, marital status, and self‑medication frequency.

Patients who fulfilled criteria for IBS had a high tendency to self‑treat their GI symptoms, use of acid‑suppressive agents was common among patients. Around one‑third of patients self‑treated GI symptoms inappropriately. Consequently, the concept of self‑medication among patients has to be revised. We recommend conduction of educational programs to improve self‑medications selection and attitude among patients to reduce the burden on other health care resources.

There are clear variations between and within countries regarding the prevalence of Helicobacter pylori. In addition, there are no estimations of its prevalence in the general population in the south of Iran.
We aimed to evaluate the prevalence of H. pylori in the rural population of Kavar, a southern city of Iran.
A random sample of 500 individuals were selected from the Kavar cohort study. Serum total IgG against H. pylori was checked. The serum positive patients recalled for stool sampling and the H. pylori stool antigen was checked using sandwich ELISA. Moreover, age and gender were recorded for all patients.
Among the remained 441 who participated, 254 patients (57.6%) were positive for serum IgG. A total of 14 patients (5.5%) gave up due to stool sampling unsatisfaction. Overall, the rate of H. pylori infection based on both serum IgG and stool Ag of H. pylori was 41.5%. There were no significant association between gender and H. pylori stool antigen positivity (P = 0.776). Furthermore, no differences were detected between different ages categorized in positivity for stool antigen of H. pylori (P = 0.327). The mean and SD of age for negative and positive groups were 40.98 ± 15.42 and 43.65 ± 15.65 years, respectively (P = 0.267).
The prevalence of the H. pylori infection in our study based on serum IgG and stool Ag positivity was 41.5%, which are lower than many previous reported rates. Further studies in larger sample size and in different rural populations are needed.

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.

Some evidence, not in large study populations, suggests that nonalcoholic fatty liver disease (NAFLD) and metabolic syndrome (MetS) share common interactions. We aimed to determine the prevalence of NAFLD and MetS in a large population registered to Kavar Cohort Study center. We also assessed the role of each component of MetS in NAFLD existence.
Data were obtained from 3415 volunteers who called and refereed to our center. Complete anthropometric and laboratory measurement and abdominal ultrasonography was done for these individuals to screen NAFLD and its grade. A questionnaire was also used to obtain information on demographical and medical history and alcohol consumption. MetS was defined in all participants based on the National Cholesterol Education Program Adult Treatment Panel III (2001) (NCEP/ATP-III) and criteria for clinical diagnosis of metabolic syndrome in Iranian adults (CCDMIA).
Among the refereed individuals, 2980 peoples were aged ≥18 years with male to women ratio of 1:2.45. NAFLD was diagnosed by ultrasound in 32.9% and 27.4% of men and women, respectively. MetS was detected in 65.9 and 64.6 of the patients with NAFLD (based on NCEP/ATP-III) and in 30.1% and 73.7% (based on CCDMIA) of men and women, respectively. There were no significant differences between two gender in none of the components (P>0.05). Although, OR for hyperglycemia and abdominal obesity were approximately high in CCDMIA criteria (0.9613 and 1.2082, respectively), the differences were not statistically significant.
NAFLD was associated with MetS. However, it was not possible to determine whether NAFLD predating the development of MetS.

Metronidazole is a main stay of modern multidrug therapies for Helicobacter pylori (H. pylori) infection. Metronidazole resistance reduces the effectiveness of these combinations. Various methods have been used for the determination of the sensitivity of H. pylori to metronidazole with conflicting results. The aims of this study were: 1) to compare the E-Test and disk diffusion methods for determining the susceptibility of H. pylori to metronidazole; and 2) Metronidazole resistance in H. pylori has been found to be associated with mutations in rdxA. The role of this gene in metronidazole resistance in H. pylori was examined in this study. A total of 46 H. pylori strains from 223 consecutive patients were examined. The E-Test was performed according to the manufacturer's guidelines, and the disk diffusion according to standard procedure using 5-μg metronidazole disks. DNA was extracted from all H. pylori isolates by boiling & phenol-chloroform methods and then Polymerase Chain Reaction (PCR) was performed.  Metronidazole resistance as determined by E-test and disk diffusion methods was 64.3% and 47.6% respectively. None of the resistant or sensitive samples possessed rdxA gene deletion. Disk diffusion method is not reliable in determining metronidazole resistance in H. pylori. An intact rdxA gene has also been reported in metronidazole-resistant H. pylori, suggesting that additional metronidazole resistance mechanisms exist in H. pylori and even molecular methods are not reliable for the detection of resistance.

Fasciola hepatica (F. hepatica) as a foodborne trematode can occasionally cause hepatobiliary diseases. We report a 67-year-old woman who was referred to our center because of the diagnosis of cholangitis. She was a resident of mountainous area with the history of unsafe water and contaminated vegetables. Endoscopic retrograde cholangiopancreatography (ERCP) was performed as a diagnostic and therapeutic modality for her. Three living F. hepatica was removed from biliary tract with a basket via ERCP. Clinical and laboratory condition of the patient improved after therapy of antibiotics and triclabendazole.

Gastroesophageal reflux disease (GERD) is a very common disease. This review focuses on the management strategies for patients with this disease. We review the initial and maintenance therapy of GERD. We also review different management of recurrent and refractory GERD.