Middle East Journal of Digestive Diseases
Volume:15 Issue: 1, Jan 2023

Studies on the use of fecal immunochemical test (FIT) in colorectal screening have long assumed perfect accuracy for colonoscopy. No study to date has directly compared the diagnostic accuracy of colonoscopy and FIT to detect advanced neoplasia (AN) in a head-to-head diagnostic accuracy meta-analysis.

A comprehensive electronic search was performed for a head-to-head comparison of FIT and colonoscopy using a third acceptable reference standard in asymptomatic adults. Cochrane methodology was used to perform a head-to-head diagnostic test accuracy (DTA) meta-analysis. Quality assessment tool for diagnostic accuracy studies-2 (QUADAS-2) was used to assess the risk of bias in included studies.

Two studies met the eligibility criteria. Overall sensitivity and specificity were 98.5 (95% CI 96.3-100%) and 100% (99.9-100%) for colonoscopy and 16.4% (10.3-22.6%) and 95.4% (94.3-96.4%) for FIT. Colonoscopy was significantly better than FIT (P < 0.0001). The positive and negative likelihood ratios (LRs) were 1.75 (1.57-1.96) and 0.03 (0.01-0.08) for colonoscopy and 3.02 (2.01-4.55) and 0.88 (0.82-0.95) for FIT, respectively.

Colonoscopy provides significantly better diagnostic accuracy to detect AN compared with FIT (GRADE: ⨁⨁◯◯). Our study provided precise sensitivity and specificity of both colonoscopy and FIT and a revision in screening policies based on an updated cost-effectiveness analysis considering the results of the head-to-head analysis.

The ideal combination regimen for Helicobacter pylori (HP) eradication has not yet been determined and the success rate of HP eradication has been extensively reduced worldwide due to increasing antibiotic resistance. So this multinational multi-center randomized controlled trial was designed to evaluate the efficacy of tetracycline +levofloxacin for HP eradication.

During a 6-month period, all of the cases with HP infection in eight referral tertiary centers of three countries were included and randomly allocated to receive either tetracycline + levofloxacin or clarithromycin plus amoxicillin quadruple regimen for two weeks. For all of the participants, pantoprazole was continued for 4 more weeks and after one to two weeks of off-therapy, they underwent urea breath test C13 to prove eradication.

Overall 788 patients were included (358 male (45.4%), average age 44.2 years). They were diagnosed as having non-ulcer dyspepsia (516 cases, 65.5%), peptic ulcer disease (PUD) (234 cases, 29.69%), and intestinal metaplasia (38 cases, 4.8%). Racially 63.1% were Caucasian, 14.5% Arab, 15.6% African, and 6.1% Asian. The participants were randomly allocated to groups A and B to receive either tetracycline + levofloxacin or clarithromycin. Among groups A and B in intention to treat (ITT) and per protocol (PP) analysis, 75.2% & 82.1% (285 cases) and 67.5% & 70.1% (276 cases) of participants achieved eradication, respectively (P = 0.0001). The complete compliance rate in groups A and B were 84.4% and 83.6%, respectively. During the study, 33.5% of the participants in group A (127 cases) reported side effects while the complication rate among group B was 27.9% (114 cases, P = 0.041). The most common complaints among groups A and B were nausea and vomiting (12.6% & 9.3%) and abdominal pain (4.48% & 2.68%), respectively. The rate of severe complications that caused discontinuation of medication in groups A and B were 2.1% and 1.46%, respectively (P = 679). In subgroup analysis, the eradication rates of tetracycline+levofloxacin among patients with non-ulcer dyspepsia, PUD, and intestinal metaplasia were 79.4%, 88.1%, and 73.9%, respectively. These figures in group B (clarithromycin base) were 71.3%, 67.6%, and 61.5% respectively (P = 0.0001, 0.0001, and 0.043).

Overall, the combination of tetracycline+levofloxacin is more efficient for HP eradication in comparison with clarithromycin+amoxicillin despite more complication rate. In areas with a high rate of resistance to clarithromycin, this therapeutic regimen could be an ideal choice for HP eradication, especially among those who were diagnosed with PUD.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumor originating from the gastrointestinal tract and have a broad spectrum of clinicopathological features affecting disease management regarding the treatment modalities.

A retrospective study of 49 patients who underwent surgery for gastrointestinal tumors between 2008 and 2016 was conducted. Clinical, pathological, and immunohistochemical features of patients with and without recurrence were statistically analyzed.

Twenty-nine (59.1%) patients had gastric; 16 (32.6%) had small intestinal; 3 (6.1%) had mesenteric; and 1 (2.2%) had rectal GISTs. Microscopic tumor necrosis and tumor ulceration were also significant for disease recurrence (P = 0.005, P = 0.049). High-risk patients according to Miettinen’s risk classification were more likely to develop a recurrence (P < 0.001). Additionally, high-grade tumors were also a risk factor for recurrence (P < 0.001). Ki-67 levels were available in 40 patients and the mean Ki-67 level was 16.8 in patients with recurrence, which was a significant risk factor in regression analysis (HR: 1.24, 95%, CI: 1.08-1-43). Five-year disease-free survival rates of non-gastric and gastric GISTs were 62.3% and 90%, respectively (P = 0.044).

Larger tumors and higher mitotic rates are more likely to develop recurrence. High Ki-67 levels were also associated with recurrence. 

Liver biopsy remain as the gold standard for diagnosing hepatic fibrosis; however, it has some limitations, such as life-threatening complications, low acceptance by the patients, and variations in the related sample. Therefore, there is a need for the development of non-invasive investigations for diagnosing hepatic fibrosis. Vibration-controlled transient elastography (VCTE) is one of these non-invasive methods.

This study included 73 patients suffering from non-alcoholic fatty liver disease (NAFLD) who were older than 18 years. The patients underwent VCTE at the Baqiatallah and Firoozgar hospitals. Then, they underwent a liver biopsy by an experienced radiologist in the same hospital. A receiver operating characteristic (ROC) curve of different fibrosis stages was used to evaluate the VCTE verification.

VCTE could detect any fibrosis levels (stage 1 and higher) with an area under the ROC curve (AUROC) of 0.381. Moreover, it detected stage 2-4 fibrosis with an AUROC of 0.400, stage 3-4 fibrosis with an AUROC of 0.687, and stage 4 fibrosis with an AUROC of 0.984.

The VCTE has high clinical validity in diagnosing the advanced stages of fibrosis (stages 3, 4) and can be a suitable alternative to the invasive method of liver biopsy with high reliability. 

Cyclic vomiting syndrome (CVS) is a chronic functional gastrointestinal disorder. It is characterized by recurrent episodes of vomiting typically separated by periods of symptom-free or baseline health. The present study aimed at evaluating the effectiveness of propranolol and the relapse rate of clinical symptoms after stopping treatment in children suffering from CVS.

Records of 504 patients below the age of 18 years with CVS who were treated with propranolol from March 2008 to March 2018 were reviewed. The duration of follow-up was 10 years.

The average age of CVS affliction was 4.3 years and the average age at the diagnosis was 5.8 years. All subjects were treated with propranolol (for an average of 10 months). 92% of treated subjects were cured, causing a dramatic decrease in the rate of vomiting (P < 0.001). Only an average of 10.5% of the studied subjects (53 people) showed a relapse of symptoms after stopping the treatment. The results of a 10-year follow-up period of the patients showed that 24 had abdominal migraine and 6 had migraine headaches, all of whom lacked the symptoms of disease relapse (prognostic evaluation).

The findings of this investigation show that the duration of treating CVS with propranolol could be shortened to 10 months with a low percent of symptoms relapse and this shortening may be effective in preventing the undesirable side effects of the drug. The presence of abdominal migraine and migraine headaches in patients after treatment accomplishment and the lack of disease relapse can be prognostic measures for this disease, which require intensive attention.

Gastric cancer is one of the most common types of cancer worldwide. Helicobacter pylori infection is clearly correlated with gastric carcinogenesis. Therefore, the use of a new non-invasive test, known as the GastroPanel test, can be very helpful to identify patients at a high risk, including those with atrophic gastritis, intestinal metaplasia, and dysplasia. This study aimed to compare the results of GastroPanel test with the pathological findings of patients with gastric atrophy to find a safe and simple alternative for endoscopy and biopsy as invasive methods.

This cross-sectional study was performed on patients with indigestion, who were referred to Motahari Clinic and Shahid Faghihi Hospital of Shiraz, Iran, since April 2017 until August 2017 for endoscopy of the upper gastrointestinal tract. The serum levels of gastrin-17 (G17), pepsinogen I (PGI), and pepsinogen II (PGII), as well as H. pylori antibody IgG, were determined by ELISA assays. Two biopsy specimens from the antrum and gastric body were taken for standard histological analyses and rapid urease test. A pathologist examined the biopsy specimens of patients blindly.

A total of 153 patients with indigestion (62.7% female; mean age, 63.7 years; 37.3% male; mean age, 64.9 years) were included in this study. The G17 levels significantly increased in patients with chronic atrophic gastritis (CAG) of the body (9.7 vs. 32.8 pmol/L; P = 0.04) and reduced in patients with antral CAG (1.8 vs. 29.1 pmol/L; P = 0.01). The results were acceptable for all three types of CAG, including the antral, body, and multifocal CAG (AUCs of 97%, 91%, and 88% for body, antral, and multifocal CAG, respectively). The difference in PGII level was not significant. Also, the PGI and PGI/PGII ratio did not show a significant difference (unacceptably low AUCs for all). The H. pylori antibody levels were higher in patients infected with H. pylori (251 EIU vs. 109 EIU, AUC = 70, P = 0.01). There was a significant relationship between antibody tests and histopathology.

Contrary to Biohit’s claims, the GastroPanel kit is not accurate enough to detect CAG; therefore, it cannot be used for establishing a clinical diagnosis. 

Chronic constipation is a common health concern. Defecatory disorders are considered one of the mechanisms of chronic idiopathic constipation. This study aimed to evaluate the effect of concurrent irritable bowel syndrome (IBS) on the success rate and response to biofeedback therapy in patients with chronic constipation and pelvic floor dyssynergia (PFD).

This prospective cohort study was performed at the Imam Khomeini Hospital Complex in Tehran from October 2020 to July 2021. Patients aged 18–70 years with chronic constipation and PFD confirmed by clinical examination, anorectal manometry, balloon expulsion test, and/or defecography were included. All patients failed to respond to treatment with lifestyle modifications and laxative use. The diagnosis of IBS was based on the ROME IV criteria. Biofeedback was educated and recommended to all patients. We used three different metrics to assess the patient’s response to biofeedback: 1) constipation score (questionnaire), 2) lifestyle score (questionnaire), and 3) manometry findings (gastroenterologist report).

Forty patients were included in the final analysis, of which 7 men (17.5%) and 21 (52.2%) had IBS. The mean age of the study population was 37.7 ± 11.4. The average resting pressure decreased in response to treatment; however, this decrease was statistically significant only in non-IBS patients (P = 0.007). Patients with and without IBS showed an increase in the percentage of anal sphincter relaxation in response to treatment, but this difference was not statistically significant. Although the first sensation decreased in both groups, this decrease was not statistically significant. Overall, the clinical response was the same across IBS and non-IBS patients, but constipation and lifestyle scores decreased significantly in both groups of patients with and without IBS (P < 0.001).

Biofeedback treatment appears to improve the clinical condition and quality of life of patients with PFD. Considering that a better effect of biofeedback in correcting some manometric parameters has been seen in patients with IBS, it seems that paying attention to the association between these two diseases can be helpful in deciding on treatment.

Leptospirosis is an emerging zoonosis of worldwide importance. Its distribution is closely linked to hydrometric conditions. It is characterized by a wide clinical range, from the subclinical form, or one with few symptoms; which resolves spontaneously, to the multi-visceral form, known as icterrohemorrhagic disease or Weil’s disease, with a lethal risk. All organs can be affected but with variable frequency. Pancreatic involvement is not well documented. We describe a 45-year-old man with Weil’s disease associated with acute necrotizing pancreatitis. The evolution was favorable but required a three-week stay in the intensive care unit.

Foreign body ingestions are common medical emergencies. In adults, foreign body ingestions occur in patients with psychiatric disorders and prison inmates. A majority (80-90%) of foreign bodies pass spontaneously. Endoscopic and surgical interventions are required in only 10-20% and 1%, respectively. A plain radiograph may be the only diagnostic test required. A computed tomography scan may be needed when a perforation is suspected. Food boluses are the most commonly ingested foreign bodies. Snare and rat tooth forceps are frequently used accessories for the retrieval of foreign bodies. The focus of the emergency team is on the management of an acute case of foreign body ingestion, and the psychiatric aspect of the disease gets often ignored.

Lymphangiomas are benign lymphatic system abnormalities that can appear anywhere on the skin and mucous membranes. Lymphangiomas are caused by congenital or acquired lymphatic system disorders. In the congenital form, although the cause is unknown it is said that it is formed by the incorrect attachment of lymphatic channels to the main lymphatic drainage duct before the age of 5 years. lymphangiectasia as a subgroup of lymphangioma occurs seldom in the small bowel, especially in adults. If that happens, protein-losing enteropathy will be the most common presenting sign. In the present study, we introduce a case of a 40-year-old man without a history of any congenital or acquired diseases who was admitted to the emergency room due to long-lasting obscure overt gastrointestinal (GI) bleeding. Normal upper and lower GI endoscopies were suggestive of GI bleeding originating from the small intestine. Despite receiving iron supplements, he continued to have melena and remained anemic. Further evaluation of the small intestine by deep enteroscopy revealed multiple white spots histologically consistent with dilated lymphatics. Intestinal lymphangiectasia was eventually introduced to be the final diagnosis of the patient.

Cytomegalovirus (CMV) colitis occurs commonly in immunocompromised patients with high mortality. CMV infection has also been reported in immunocompetent individuals and it has a varied clinical presentation. When HIV-infected patients are started on antiretroviral therapy (ART) there is a reconstitution of the immune system which results in the paradoxical worsening of existing conditions or development of new disease conditions known as immune reconstitution inflammatory syndrome (IRIS). In the setting of IRIS one of the most common infections to occur is non-tubercular mycobacteria (NTM). The infection generally develops when the CD4 count is < 50 cells/μL. Here we present a rare case of CMV colitis followed by NTM infection in the setting of IRIS, its management, and treatment outcomes.

In the worldwide medical literature, only one case of inlet patch shows a kissing pattern on endoscopy. This article describes a 69-year-old female patient who came to the gastroenterology clinic, Rohani hospital, Babol University of Medical Sciences (Iran) for an examination for indigestion. Endoscopy showed two polyps in the background of a maroon patch just below the upper esophageal sphincter, oppositely positioned in view of the kissing pattern, and extending into muscular mucosa and regional lymph nodes. There was no A polyp biopsy was performed and, on histological evaluation, there was heterotopic cardiac gastric mucosa. Since heterotopic gastric mucosa can be found anywhere in the gastrointestinal tract, careful examination of the proximal esophagus increases the likelihood of detecting an inlet patch.