Middle East Journal of Digestive Diseases
Volume:5 Issue: 4, Oct 2013

Hepatocellular carcinoma (HCC) represents one of the most common neoplasms worldwide. Liver trasnplantation (LT) is the treatment of choice for selected group of patients with HCC. LT is actually a consolidated therapeutic option for HCC because it cures both tumor and underlying cirrhosis. In 1996, the publication of a pivotal prospective study on less than 50 patients, transplanted for HCC under predefined criteria (single HCC ≤ 5 cm or 3 HCC ≤ 3 cm each), the so called “Milan criteria”, showed a 4-year survival of 75%.However, the indication of LT for HCC treatment has evolved over recent years.The possibility of an extension of Milan criteria as indication for LT is already a debated issue.Living donor LT (LDLT) is an alternative option if waiting list is long and offers the possibility of a LT after a short time.In this review, the current indications and results of liver transplantion for HCC have been dsicusssed.

Corticosteroids are used to induce remission in auto-immune hepatitis. They are not universally effective; therefore, alternative treatments are needed. In this study Cysclosporine-A has been compared with prednisolone as an alternative treatment in a randomized controlled trial. This paper is an interim analysis of an ongoing clinical trial. Sixteen years and older consenting patients were enrolled. Group-A received prednisolone and group-B cyclosporine-A according to a preset protocol and followed at regular intervals for 48 weeks. Final assessment was done at week 48. Primary outcome was response rate as defined below. “Complete response” was defined as achieving AST and ALT in the normal range and absence of any clinical signs of deterioration, and partial response was defined as a decrease in AST and ALT by less than half of their original values but not to within normal limit. Non-responding ones at week eight were switched to the other arm. Thirty-nine patients were enrolled (24 group-A, 9 male). Mean AST and ALT at baseline were higher in group-B, but other variables were comparable. At week 12, 34.8% and 64.3% of group-A and B had achieved AST and ALT in the normal range (less than 40 IU/L) respectively (p=0.081). Corresponding figures at week 48 were 50.0% and 47.6% (p=0.62 & 0.48 respectively). At week 12, 86.9% and 85.7% of patients had AST and ALT levels less than twice upper normal limit in groups-A and B respectively (P=0.54 & 0.42). Corresponding figures at week 48 were 90.0% for both groups. There was one treatment failure in group-B which did not respond to prednisolone either. Serious adverse events (death and liver transplantation) occurred in group-A only. Serum creatinine did not change during the study period in either group. According to our data, Cyclosporine-A is as effective as prednisolone for induction of remission in AIH. Adverse events and serious adverse events were more common with prednisolone.

A considerable portion of gastrointestinal malignancies undergoes surgery without curative resection. This study was conducted to assess surgical outcome in patients with gastrointestinal cancers.We reviewed individuals with esophagus, stomach, colon and rectum cancers admitted for surgical treatment after initial preoperative evaluations. Surgical outcome, stage of tumors and 1 and 5 years survival rate were assessed and analyzed. Two hundred and fifty five patients with esophagus, stomach and colorectal malignancies, who were admitted for surgical resection, were reviewed. Two hundred and twenty two patients were underwent surgery but tumor was not resected in 41 cases (18.6%). Based on pathological assessment, stage of tumors was III or IV in 108 individuals (48.9%). The proportion of tumor with advanced stage was significantly higher in patients with gastroesophageal cancers than those with colorectal malignancies (62.6% versus 31.6%), p<0.0001). The proportion of non-resectable tumor was also significantly higher in patients with esophageal and gastric cancers (p=0.0001). Palliative surgery was done in 26.1% of patients treated by surgical resection. The proportion of palliative surgery was significantly lower in patients with gastric cancer (p=0.001). 1 and 5-year survival were significantly longer in colorectal cancer and those with curative surgery (p=0.001). Survival of patients with palliative resection was the same as patient without tumor resection. Despite preoperative evaluations, there are still a considerable proportion of patients who are diagnosed as inoperable during surgery. Further researches seem to be necessary in order to provide more precise preoperative staging. Screening programs should also be considered for GI cancers in high-risk areas. It seems that palliative resection would not improve survival of patients with advanced GI malignancies.

Assessment of glomerular filtration rate (GFR) by common creatinine-based methods is potentially inaccurate in patients with cirrhosis. Cirrhotic patients have several underlying conditions that contribute to falsely low serum creatinine concentrations, even in the presence of moderate to severe renal impairment. Therefore creatinine-based methods usually overestimate true GFR in these patients. Cystatin-C is a low molecular weight protein and an endogenous marker of GFR. We compared the accuracy of plasma cystatin-C and creatinine in assessing renal function in cirrhotic patients. We serially enrolled cirrhotic patients with stable renal function admitted in our ward if they met the inclusion criteria and consented to participate. Child-Pugh (CP) score was calculated for all patients. GFR was calculated using serum creatinine, serum cystatin-C, and 99m TC-DTPA clearance with the last one serving as the gold standard. The area under curve (AUC) on receiver-operating characteristic curves (ROC) were used to assess the diagnostic accuracy of each calculated GFR with that measured by DTPA.Fourty-eight patients were enrolled (32 males, 66.7%). Nine were in class-A, 20 in class-B and 19 in class-C of CP. Cystatin-C did not perform well in predicting the true GFR, while serum creatinine performed relatively accurately at GFR<80ml/min (AUC=0.764, p=0.004). Serum creatinine at a cutoff of 1.4 mg/ dl was 20% sensitive & 92% specific and with at a cutoff of 0.9 mg/dl was 77% sensitive & 72% specific for diagnosis of impaired renal function. Cystatin-C could not predict GFR effectively even after stratification for CP score, gender, and BMI. Serum creatinine could predict GFR<65ml/min in females (ROC curve AUC=0.844, p=0.045). In those with BMI>20 kg/m2 a GFR<80 ml/min could also be predicted by serum creatinine (ROC curve AUC=0.739, p=0.034). It also could predict GFR<80ml/min in patients with CP class A & B (ROC curve AUC=0.795, p=0.01), but not in patients with CP class C. Neither serum creatinine nor Cystatin-C are good predictors of GFR in cirrhotic patients, although serum creatinine seems to perform better in selected subgroups.

Irritable bowel syndrome is one of the most common gastrointestinal disorders Characterized by chronic abdominal pain, altered bowel habits or changes in stool consistency. Unfortunately, no specific treatments for relieving IBS symptoms have been suggested yet. This pilot study was conducted to evaluate the efficacy of the Cumin extract, a kind of herbal used in the treatment of gastrointestinal disorders like bloating, and other symptoms of IBS. Fifty seven patients with IBS (according to the ROME II diagnostic criteria) with no nay other accompanying illness enrolled in study. Patients were advised to discontinue their other treatments during the study course, then 20 drops per day of Cumin essential oil was administered for included patients. IBS‐associated symptoms including abdominal pain, nausea, painful defection, presence of mucosa in stool, changes in stool consistency and defecation frequency were evaluated using a questionnaire before treatment, 2 and 4 weeks after beginning treatment and 2 and 4 weeks after stopping treatment. Abdominal pain, bloating, incomplete defecation, fecal urgency and presence of mucus discharge in stool were statistically significant decreased during and after treatment with Cumin extract. Stool consistency and defecation frequency were also both statistically significant improved in patients with constipation dominant pattern of IBS. Cumin extract can be effective in improving all IBS symptoms. Considering its low cost and easy availability Cumin administration in patients with IBS may have economic benefits.

Acute upper gastrointestinal bleeding (UGIB) is a common medical emergency and is known as one of the main causes of mortality and morbidity. This research was conducted to study the causes and risk factors for UGIB, in a referral center.In this cross sectional study, carried out in a one year period, all patients with acute UGIB living in Khorramabad city and surrounding area, entered the study. A control group with age and sex matched was selected from outpatient visits and their relatives who had referred to hospital clinics. Data collecting tool was a self-made questionnaire, demographic, clinical manifestations and endoscopic findings. The data was analyzed using chi-square test, Fisher exact test and Odds ratio estimation.Sixty-two patients with acute UGIB were studied, 67.7% of them were males. The mean age of patients was 54.5±12.1. The most common causes of acute UGIB were peptic (42.7%), erosive gastritis (19.8%) and esophageal varices (19.8%). 29%, and 9.7% of patients, and control group had a history of regular consumption of Non Steroidal Anti-Inflammatory Drugs (Odd'' s ratio 3.8, CI: 1.3-4.8). 35.5% of episodes of acute UGIB were in age more than 60 years.Peptic ulcer disease is the most common cause of acute UGIB in our region. Episodes of acute UGIB were correlated with regular NSAIDs use, but not with alcohol consumption, smoking, and gender. Identifying people who are at risk and providing preventive strategies can reduce the rate of this disease and its complications.

Anemia is the most common hematologic disorder in patients with ulcerative colitis (UC). In some cases, normochromic anemia results from the presence of chronic disease; however blood loss or malabsorption may lead to an iron deficiency anemia with hypochromic appearance. Other rare hematologic manifestations associated with UC include myelodysplastic syndromes and leukemia. Several investigators have suggested a clinical association between inflammatory bowel disease and myelodysplastic syndrome, which may they share an immune dysfunction and impairment of T-lymphocytes activities. UC is an inflammatory bowel disease of unknown etiology that mainly affects the mucosa of the colon. Immune mechanisms play an important role in UC, and immunogenetic factors have been implicated in the development of the disease. Aplastic anemia is a bone marrow stem cell disorder characterized by ineffective hematopoiesis, leading to pancytopenia. Although aplastic anemia is frequently idiopathic, the immune-mediated suppression of hematopoiesis may be implicated in at least half of patients, since more than half of these patients achieve hematological remission in response to immunosuppressive therapy. We report here a rare case of UC associated with pancytopenia requiring a blood transfusion in which a bone marrow examination showed aplastic anemia. A common pathogenic link between UC and aplastic anemia is suggested in this patient on the basis of the shared immunologic impairment underlying both diseases.

Blue Rubber Bleb Nevus Syndrome is a rare disorder that is characterized by multiple recurrent vascular malformations of skin and gastrointestinal tract. The affected patients may present with diverse manifestations including iron deficiency anemia. We report this syndrome in a 22-year-old man that was referred to our hospital for iron deficiency anemia with unknown cause and vascular malformations in the skin and gastrointestinal tract. Because of stable hemoglobin level, we decided to treatment him by iron supplementation and close follow up. We report this case along with a review of literature.