Showing papers in "Open Journal of Gastroenterology in 2014"

25 years’ experience in the management of pilonidal sinus disease

Abstract: Pilonidal sinus disease is a common medical condition that accounts for almost 15% of anal suppurations with high morbidity. Its management is subject to many variations. In this study, a 25-year experience from 1984 to 2009 of treating pilonidal sinus disease is being reported. A total of 252 patients were included in the study. They were treated by phenol injection, excision and primary closure, or excision and packing. Data showed that excision with packing had the highest cure rate (85%), followed by excision and primary closure (65%), and then phenol (55%). As for the healing duration, the shortest was for excision and primary closure, followed by the phenol injection. However, excision and packing had the least recurrence rate (12%), compared to phenol and excision with primary closure 26.5% and 23%, respectively. The authors recommended excision and packing. However, hospital stay, missed days of work, recurrence rates, and the surgeon’s familiarity with the techniques were important factors in the choice of treatment modality.

Epidemiological Aspects of Intrafamilial Spread of HCV Infection in Egyptian Population: A Pilot Study

Abstract: Aim: Liver disease is a leading cause of morbidity and mortality among Egyptians. The major cause is infection with HCV, with 70 000 up to 140 000 newly reported cases annually. The objectives of this study were to determine the prevalence of anti-HCV antibodies among household contacts of HCV index cases and to identify the possible risk factors of transmission of HCV among Egyptian families. Material and Methods: The present external pilot study (double centre study) was performed on a convenient sample of 125 index cases and their 321 household family contacts recruited from Mansoura & Cairo University where 2 questionnaires were used to collect data from the index & their related contacts. The all were exposed to clinical examinations, routine laboratory testing & screening for the prevalence of Anti-HCV antibodies. Results: The prevalence of anti-HCV seropositivity among household contacts of index cases was found to be 13.7% which husbands of female index cases ranked first followed by wives of male index cases (36.36% versus 17.86% respectively, P

Eosinophilic esophagitis in Egyptian adult patients presenting with upper gastrointestinal symptoms

Abstract: Background and Study Aim: Eosinophilic esophagitis (EoE) is a clinicopathological disease characterized by esophageal dysfunction and marked esophageal eosinophilic infiltration. It shows a marked increase in incidence and prevalence and has been associated with gastroesophageal reflux disease (GERD). The aim of this work was to detect the prevalence of EoE in Egyptian adult patients presenting with upper gastrointestinal symptoms and to clarify its clinical pattern and the possibility of its overlap with GERD. Patients and Methods: The study included 91 adult patients presenting with various upper gastrointestinal symptoms. Upper gastrointestinal endoscopy was done and esophageal biopsies were taken. The presence of >15 eosinophils per high power field together with a history of intake of proton pump inhibitors for at least 3 weeks without improvement was used as prerequisite diagnostic criteria for EoE. Results: Classification of the patients was based on both endoscopic and histo-pathological findings. Accordingly, out of the 91 patients, 70 had GERD (76.9%); 58 of them had erosive reflux disease (ERD) and 12 had endoscopically normal esophagus but with histopathological changes compatible with reflux esophagitis and were classified as non erosive reflux disease (NERD). Eighteen patients had normal endoscopic and histopathological esophagus (19.8%), and 3 patients had EoE (3.3%), with an overlap between ERD and EoE in one patient. The mean age of EoE patients was 41.6 ± 11.7 years. Two of them were males and one was a female. All of the 3 patients complained of dysphagia and none complained of heartburn. The endoscopists did not report any endoscopic findings characteristic of EoE. Conclusion: The prevalence of EoE is low in adult Egyptian patients presenting with upper gastrointestinal symptoms. Dysphagia is the main presenting symptom of EoE while heartburn is not characteristic of the disease. Normal esophagus endoscopically does not exclude EoE.

The effect of melatonin in functional heartburn: A randomized, placebo-controlled clinical trial

Abstract: Background: Melatonin is a safe and effective treatment for patients with functional pain and gastrointestinal disorders. Objective: To evaluate the efficacy and safety of melatonin for 3 months in patients with functional heartburn. Methods: In the randomized, placebo-controlled pilot study, patients with functional heartburn were treated with omeprazole 20 mg before breakfast and randomized to receive either melatonin 6 mg (n = 20), nortripty line 25 mg (n = 20), or placebo (n = 20) at bedtime for 3 months. Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQOL) scores were assessed at baseline and at the end of the study. Results: Melatonin improved GERD-HRQOL scores compared with nortriptyline (P = 0.0015) and placebo (P

Predictors of Intra-Hospital Mortality in Patients with Cirrhosis

Abstract: Intra-hospital mortality in cirrhotic patients is variable depending on the studies reported in literature. Several studies have demonstrated independent predictors of mortality. The aim of this work is indeed to identify these predictors. Patients and Methods: We conducted a retrospective study of 1080 cirrhotic patients hospitalized in our department of gastroenterology and hepatology between January 2001 and August 2010. A descriptive study of the study population was performed, and a univariate analysis looking for an association between intra-hospital mortality, and clinical, biological, etiological and sociodemographic characteristics of our patients. Results: The average age of our patients was 54 years, with an equal number of men and women. 41.1% of patients had cirrhosis secondary to hepatitis C and 18.5% had cirrhosis secondary to hepatitis B. 26.1% of our patients were CHILD C. Intra-hospital mortality was 8.7% (97 deaths) with a mean of 23.4 ± 35.8 months. Univariate analysis showed that the intra-hospital mortality was significantly associated with higher age (p = 0.049) as well as the reasons for admissions like hepatic encephalopathy, and hematemesis (p < 0.0001), melena, jaundice and ascites (p = 0.001). Among the biological parameters analyzed in univariate analysis, significant associations with mortality were objectified for high white blood cell count (p = 0.035), and high serum bilirubin and creatinine (p < 0.0001); low rate of prothrombin time (PT) (p < 0.0001), of albumin (p = 0.0001) and of serum sodium (p < 0.0001). Among the complications analyzed, significant associations with mortality were objectified for jaundice, ascites (p = 0.001), hemorrhagic decompensation, hepatic encephalopathy, and spontaneous bacterial peritonitis (p < 0.001). Univariate analysis of the etiology of cirrhosis objectified significant associations for cirrhosis secondary to hepatitis B (p = 0.001) and hepatitis C (p = 0.022). Multivariate analysis objectified four independent predictors of mortality: hepatic encephalopathy, infection (hyper leukocytosis ≥ 10,000/mm3), renal failure (serum creatinine ≥ 15 mg/l) and hyponatremia. Conclusion: In our series, we identified four independent predictors of intra-hospital mortality in cirrhotic patients: hepatic encephalopathy, infection, renal failure and hyponatremia.

Serum-Derived Bovine Immunoglobulin/ Protein Isolate Therapy for Patients with Refractory Irritable Bowel Syndrome

Abstract: Background: A small double-blind study showed benefits of serum-derived bovine immunoglobulin/protein isolate (SBI), for diarrhea-predominant irritable bowel syndrome (IBS-D) [1]. The purpose of this chart review was to assess safety and clinical outcomes of SBI in refractory irritable bowel syndrome (IBS) patients. Methods: A retrospective review of 35 IBS patients with diarrhea or mixed diarrhea/constipation pattern (IBS-M) who were administered SBI 5 grams twice daily was performed. Clinical response (“good response” or “no response”) and adverse events were determined by follow-up after four weeks of therapy. Patients were included for evaluation if a lactulose breath test (LBT) had been performed prior to SBI. All patients were refractory to common IBS therapies. The response rate to the inclusion of SBI was calculated in three separate groups: dividing patients based on their LBT results (positive or negative), dividing patients by their IBS diagnosis (IBS-D or IBS-M) and grouping all patients together. Results: Analysis was carried out on 26 IBS-D/-M patients with LBT results. Two patients were lost to follow-up and were excluded from data analysis. The positive LBT group (N = 11) had a 73% (p = 0.117) positive response rate to SBI. The negative LBT group (N = 13) had a significant response rate of 77% (p = 0.040). If patients were divided by IBS diagnosis or grouped together, the response rate to SBI was similarly ranging from 69% - 88%. Adverse events leading to cessation of SBI occurred in 3 of 24 patients. Conclusion: SBI appeared to be a safe and effective nutritional moiety in refractory IBS-D and IBS-M patients. Larger, double-blind studies are needed.

Evaluation of Venous Ammonia Level, Splenic Longitudinal Diameter, Portal Vein and Splenic Vein Diameters as Non-Invasive Indicators for the Presence of Portosystemic Collaterals in Egyptian Cirrhotic Patients

Abstract: Introduction and Aim of the Work: The identification of cirrhotic patients with esophageal varices or other portosystemic collateral by non-invasive means is appealing in that it could decrease the necessity of endoscopic screening. This study was to evaluate the diagnostic utility of venous ammonia level with other ultrasonographic parameters as non-invasive markers for the presence of portosystemic shunts. Patients and methods: The study included 3 groups of Child Pugh class A and early B patients. Group (A): 25 patients with evidence of both esophageal varices and portosystemic collaterals; group (B) 25 patients with neither evidence of varices nor portosystemic collaterals and group (C): 25 patients with evidence of varices but no collaterals. Measurement of venous ammonia level was done for all patients. Results: serum ammonia level was significantly higher in group A (222.8 ± 54 μg/dL) than that in group B (85 ± 21.1 μg/dL) and group C (148.2 ± 19.6 μg/dL). The cut-off value of serum ammonia level 113 μg/dL was a good predictor for the presence of esophageal varices, while the cut-off value of serum ammonia level at 133 μg/dL was a good predictor for the presence of both esophageal varices and abdominal collaterals. Combination of portal vein diameter > 13mm + splenic vein diameter > 8.9mm + ammonia level > 133 μg/dL gives 100% of sensitivity and 96% of specificity for the prediction of the presence of portosystemic shunts. Conclusion: Determination of serum ammonia level, splenic, portal vein and splenic vein diameters are considered as good predictors for the presence of portosystemic shunts in patients with liver cirrhosis.

Effect of Vitamin E and Alpha Lipoic Acid in Nonalcoholic Fatty Liver Disease: A Randomized, Placebo-Controlled, Open-Label, Prospective Clinical Trial (VAIN Trial)

Abstract: Objective: Antioxidants, including alpha lipoic acid (ALA) and vitamin E, are efficacious for the treatment of nonalcoholic fatty liver disease (NAFLD). The objective was to evaluate the effects of ALA and vitamin E alone or combined as therapy for patients with NAFLD and nonalcoholic steatohepatitis (NASH). Design: Placebo-controlled, open-label, prospective study in which patients with NAFLD and NASH were randomized to treatment with ALA 300 mg (n = 40), vitamin E 700 IU (n = 40), ALA 300 mg plus vitamin E 700 IU (n = 40), or placebo (n = 35) daily for 6 months. Body mass index, homeostasis model assessment scores, fibrosis and steatosis markers, and diagnostic laboratory tests were assessed at baseline and at the end of the study. Results: Treatment with ALA and vitamin E alone or in combination, improved inflammatory cytokine levels, steatosis scores, homeostasis model assessment scores, and triglyceride levels after 6 months relative to baseline. Conclusion: Alpha lipoic acid and vitamin E, either alone or in combination, were effective treatments for patients with NAFLD and NASH.

Presence of the Genes cag A, cag E, vir B11 and Allelic Variation of vac A of Helicobacter pylori Are Associated with the Activity of Gastritis

Abstract: Non-atrophic active chronic gastritis (ACG) is characterized by the presence of H. pylori in the gastric epithelium, known to be one of the first steps that precede progression to gastric adenocarcinoma. Inactive chronic gastritis (ICG) suggests that the patient has H. pylori gastritis, but this diagnosis is rarely made in routine histopathology. Clinical manifestations associated with H. pylori infection are potentially due to differences in virulence between strains; however, it is unclear if the progression of ACG to ICG depends on the H. pylori strain. The aim of this study was to compare the prevalence of the virulence factors of H. pylori found in patients with ACG and ICG, and its influence on the development of ICG. A significant association was observed between H. pylori detection by histological examination and the activity of gastritis (p 1 year) was reported by 28.6% of the ACG group and 42.5% of the ICG, while no evidence of association between long-term use of PPI and decreased inflammation was found in the patients studied. The genes cagA, cagE and virB11 were statistically associated with ACG (p = 0.01, p < 0.001 and p = 0.002, respectively). In the vacAs1 allele groups, ACG was associated with the most virulent group (p = 0.0015), while ICG was associated with the less virulent group (p < 0.001). The rate of co-infection was significantly higher in ICG than in ACG cases (p = 0.02). In conclusion, this study points to the role of virulent strains of H. pylori in the non-resolution of gastritis.

Primary cancers of the small bowel: About 20 cases

Abstract: Background: Cancers of the small bowel are rare. Diagnosis is late and difficult because of the lack of specific signs. Treatment is surgical. Prognosis is usually poor and depends on the histological type of tumor. Aim of Study: To specify the epidemiological, clinical and therapeutic characteristics of small bowel primary cancers in order to improve their prognosis. Material and Methods: This is a retrospective study about 20 cases of malignant tumors of the small bowel, collected in the department of general surgery of Habib Thameur Hospital in Tunis (Tunisia), from January 1994 through June 2011. Results: Our series involved 11 women and 9 men aged 62 on average (range: 44 - 80 years). In 45% of cases, the diagnosis was made in a patient rushed to hospital with clinical features of acute generalized peritonitis (66% of all surgical emergencies). Intestinal transit was performed in 5 patients only. Ultrasound abdominal examination was performed in 11 patients. Abdominal CT scan was performed in 7 patients, but the results were conclusive in 4 cases only (57%). Small bowel scanning was done in 5 patients only, but led to a positive diagnosis in all of them. All of our patients underwent surgery. Tumors of the small bowel were histologically divided as follows: carcinoid tumor (8 cases), leiomyosarcoma (7 cases), giant B-cell lymphoma (2 cases), malignant stromal tumor (2 cases) and malignant myxoid schwannoma (1 case). Malignant tumors of the small bowel most commonly arise in the ileum (60%) followed by the jejunum (35%). As for the long-term course, there was a recurrence at one year of a leiomyosarcoma and two recurrences of stromal tumors associated with liver metastases. Conclusion: Small bowel cancers are rare. Time to consultation is long and diagnosis is difficult and late due to the absence of typical presentation. Treatment is surgical and progression depends essentially on histological findings.

Predictors of Bleeding from Esophageal Varices: The Role of Factor VII and von Willebrand Factor (vWF)

Abstract: Objectives: Bleeding from gastroesophageal varices is the most serious and life-threatening complication of cirrhosis and accounts for 10% of all cases of bleeding from the upper GI tract. It is essential to identify and treat those patients at the highest risk because each episode of variceal hemorrhage carries a 20 percent to 30 percent risk of death, and up to 70 percent of patients who do not receive treatment die within one year of the initial bleeding episode. The aim of this study is to determine the clinical predictors of bleeding esophageal varices and study the role of F VII (factor VII) and vWF (von willebrand factor) in predicting bleeding in patients with eosphogeal varices. Methods: A case control study was done on all patients with esophageal varices admitted at Sohag and Qena faculty of medicine hospitals from January 2012 to August 2013. Various clinical, laboratory and endoscopic variables were tested to determine the predictors of esophageal bleeding. Results: Among 300 patients with esophageal varices, 80 percent was due to hepatitis C virus (HCV), 18 percent was due to hepatitis B virus (HBV), and 2 percent had both HCV and HBV. As an etiologic factor for their liver disease, hemoglobin was 10.12 ± 2.26 g/l, platelet count 135.55 ± 65.94 × l09/l, prothrombin time 14.1 ± 0.92 second, albumin 2.88 ± 0.71 g/dl, ALT 48.25 ± 24.15 u/l, total bilirubin 1.92 ± 1.36 mg/dl. Factor VII was 27.4 ± 8.92 percent and vWF was 188.33 ± 13.66 IU/dl. Splenomegaly was reported 79.6 percent, 90.3 percent had ascites. 35 percent had grade III esophageal varices, 29 percent had four-column esophageal varices on endoscopy, 13.7 percent had concomitant gastric varices and 38.3 percent had portal hypertensive gastropathy. Platelet count, presence of red color sign, the number of columns of esophageal varices, presence of portal gastropathy on eosphagogastroduodenoscopy (EGD) showed a significant positive correlation with bleeding. There is a significant decrease of FVII and a significant increase of vWF in bleeding group in comparison with non bleeding group. Conclusion: Thrombocytopenia, presence of encephalopathy and endoscopic findings of large varices, presence of red color sign, and portal hypertensive gastropathy were found to be predictors of esophageal variceal bleeding. Increase of vWF and decrease of FVII are laboratory predictors of esophageal variceal bleeding.

Comparison between FIB-4 Index and Fibroscan as Marker of Fibrosis in Chronic HCV Infection in Egyptian Patients

Abstract: The FIB-4 index is a simple and noninvasive algorithm consisting to evaluate liver fibrosis in chronic HCV infection. Aim: To evaluate the utility of FIB-4 index as a noninvasive marker to assess liver fibrosis in chronic HCV infection in comparison to transient elastography. Patients and Methods: We studied 30 patients having chronic HCV infection based on clinical features, laboratory tests, diagnostics images, Fibroscan and FIB-4 score. According to the results of Fibroscan, the 30 patients were classified into two groups in order to obtain a cutoff value to exclude patient with significant fibrosis: group Ia: 7 patients with no or mild liver fibrosis (F0-F1) and group Ib: 23 pa-tients with significant fibrosis or cirrhosis (F2-F3-F4). Group IIa: 17 patients with no or significant fibrosis (F0-F1-F2-F3) and group IIb (F4): 13 patients with cirrhosis (F4). Results: The mean of FIB-4 index increased with the increase of the fibrosis score. FIB-4 index proved to be sensitive and specific in differentiation between patients with no or mild fibrosis (F0-F1) and patients with significant fibrosis or cirrhosis (F2-F3-F4) with the best cutoff value at 1.61. It also proved to be sensitive and specific in differentiation between patients with no or significant fibrosis (F0-F1-F2-F3) and patients with cirrhosis (F4) with cutoff value at 1.88. Conclusion: The FIB-4 index enabled the correct identification of extreme types of fibrosis. Using these cutoffs (1.61 - 1.88), 87% of patients fell outside these ranges and could thus avoid liverbiopsy with an overall accuracy of 70%.

Case Series of 10 Drug-Refractory IBS Patients Who Respond to Oral Serum-Derived Bovine Immunoglobulin/Protein Isolate (SBI)

Abstract: Aim: The responses of 10 patients with long-standing, symptomatic, intractable drug-refractory histories of irritable bowel syndrome with diarrhea (IBS-D) and with abdominal pain, gas/bloating and distention, termed IBS undefined (IBS-U), were evaluated when administering a medical food product containing serum-derived bovine immunoglobulin/protein isolate (SBI). Methods: Patients in this case series were chosen based on their lack of satisfactory response to a variety of drugs, including antidiarrheal and antispasmodic medications, serotonin 5-HT3 receptor antagonists, selective serotonin re-uptake inhibitors (SSRIs), proton pump inhibitors (PPIs), antibiotics, and antidepressive drugs. Patients met Rome III criteria and were administered 5 g/day of SBI as standard-of-care nutritional support. A scale of 0% - 25%, 25% - 50%, 50% - 75%, 75% - 100% response to SBI was used for patient-reported improvement in overall IBS symptoms following administration for one month. Exact methods for calculating confidence intervals and p-values were used to assess complete management of symptoms and response to therapy. Adverse events were also monitored for this nutritional product. Results: The onset of gastrointestinal (GI) symptom reduction utilizing nutritional management with SBI occurred within an average time of 2-4 weeks with improved or near complete management in all 10 patients who were refractory to previous drug therapies by 4 weeks. When prompted, patients reported significant IBS symptom improvement which averaged between 50% - 100% (p = 0.002) with an average for complete management in all patients of 69%. No side effects were reported after SBI administration even when taken for up to 28 weeks. Conclusion: Based on the safety profile and reported outcomes in this case report, SBI should be considered as a nutritional option for management in IBS-D and IBS-U.

Assessment of the Nutritional Status of the Egyptian Patient with End Stage Liver Disease Prior to Liver Transplantation

Abstract: Background and Aim: Patients with advanced liver disease have several risk factors to develop nutritional deficiencies. Accurate nutritional assessment is a real challenge because many of the traditionally measured parameters of nutritional status vary with severity of liver disease independently of nutritional status. The objective of this study was to assess the Egyptian patients with end stage liver disease and to compare different tools used to assess their nutritional status. Patients and Methods: 60 patients were nutritionally assessed by SGA, RFH-SGA anthropometry, handgrip dynamometry and biochemical tests. Clinical variables were cross analyzed with the nutritional assessment methods. Results: Malnutrition ranged from 7% by BMI and 100% by SGA. Agreement among all the methods was low compared with the SGA. Correlation between Malnutrition prevalence and the severity of liver disease was verified using Child-Pugh score more than MELD score. Conclusion: Malnutrition is highly prevalent among the Egyptian patients with end stage liver disease prior to liver transplantation. Although the diagnosis of nutritional status is not easy among this category of patients, it varied according to the method used. Nutritional support should be an important part of the preoperative care of liver transplantation patients.

Surgical treatment and outcomes of hydatid cyst of the spleen

Abstract: Aim: Discuss the different modalities of surgical treatment of splenic hydatid cyst and outcomes after treatment. Patients and Methods: Retrospectively, 14 patients were operated in our institution between 2002 and 2011. Results: A total splenectomy was performed in 8 cases. A conservative treatment was preferred in 6 cases: 2 patients underwent partiel splenctomy and two patients underwent partial cystectomy. The duration of hospitalization ranged from 5 to 15 days. The morbidity rate was 14%. One patient presented a recurrent hemorrhage and one patient developed a left pneumonia. There is no death in our series. The mean duration follow-up was 20 months and there is no recurrence. Conclusion: Management of a splenic hydatid cyst is not consensual. Surgery remains the treatment of choice to avoid serious complications. Total splenectomy is optimal because it provides definitive treatment. However, spleen-preserving surgery is the preferred treatment in some selected patients.

Primary Care Practitioners’ Views on the Use of Proton Pump Inhibitors Associated with Alginate-Antacids for Better Gastroesophageal Reflux Disease Symptom Control: Results of a National Survey in Spain

Abstract: Background: Gastroesophageal reflux disease (GERD) is a prevalent disease in Western countries. Despite effective treatment modalities, in some patients total symptom control is not achieved in clinical practice. A cross-sectional study was designed to assess primary care practitioners’ views on the effectiveness of proton pump inhibitors (PPI) as monotherapy in the control of the most common symptoms of GERD (heartburn and regurgitation), as well as to determine the level of implementation of the “combined therapy” (PPI + alginate-antacids). Methods: A questionnaire on different aspects of the management of GERD was completed by 1491 primary care physicians. The questionnaire was composed of 11 close-ended questions with one-choice answer, with a total of 52 items, covering the main data from patients presenting with GERD. Results: Treatment with PPI alone was mostly considered insufficient for the control of GERD symptoms. The combined treatment of PPI + alginate-antacids was used for 37% and 21% of physicians for treating heart-burn and regurgitation, respectively. A better control of symptoms, an increase in the onset of action and to reduce nocturnal acid breakthrough were the most frequently argued reasons for the use of PPI + alginate-antacids. A high percentage of participants believed that treatment with PPI alone was insufficient for the control of symptoms and 39.8% of physicians reported the persistence of heartburn, 38.6% the persistence of regurgitation and 43.2% the persistence of epigastric discomfort in more than 25% of their patients treated with PPI as monotherapy. The most common schedule for the use of the antacid medication was on demand. Conclusions: Spanish primary care physicians consider that a high proportion of GERD patients continue to suffer from symptoms during PPI treatment alone. Ondemand “combined therapy” (PPI + antacid) is considered an efficient option to control reflux symptoms still troublesome in patients with PPI treatment alone.

Laryngopharengeal Reflux in Gastroesophageal Reflux Disease: Does “Silent Laryngopharengeal Reflux” Really Exist?

Abstract: Background: Gastroesophageal reflux disease (GERD) is a disorder resulting from the reversed flow of gastroduodenal contents into the esophagus, and producing different symptoms, while laryngopharyngeal reflux (LPR) is a disorder resulting from the reversed flow of gastric contents into the hypopharynx. The aim of this work is to evaluate LPR in cases of GERD. Methods: The present study was performed on fifty GERD patients diagnosed by gastroscope. LPR was assessed by reflux symptoms score (RSI) and reflux finding score (RFS). Accordingly, patients are classified into: Group I = 25 patients with manifest LPR, and Group II = 25 control patients without LPR symptoms. Results: GERD accounts for 17.4% of attendants of gastroscope unit, where manifest LPR accounts for 29.1% of GERD cases recording mean RSI and RFS 16.48 and 8.44 respectively. Silent LPR accounts for 8% recording mean RFS 7. Conclusion: There is a significant direct proportional relationship between severity of GERD and the RSI and RFS (p = 0.015 and 0.005 respectively).

Hemobilia Due to an Iatrogenic Arteriobiliary Fistula Complicating Laparoscopic Cholecystectomy: A Case Report

Abstract: Hemobilia is the result of a pathological communication between bile duct and intra or extrahepatic vessel. 40% to 60% of the haemobilia cases are Iatrogenic, and the other causes are either vascular malformations or hepatic blunt trauma. We describe the case history of a patient in which laparoscopic cholecystectomy was complicated 3 months later by massive hemobilia. The cause of haemorrhage was a fistula between the principal bil duct and the right hepatic artery. This complication was successfully managed by surgery and angiographic embolization with full recovery of the patient.

Efficacy of Itopride in the Prevention of Lubiprostone-Induced Nausea

Abstract: Background: The efficacy of lubiprostone for chronic constipation has been established through phase III clinical trials. Nevertheless, the continuation of lubiprostone therapy is reportedly difficult due to the development of nausea. The objective of this study is to determine whether the administration of itopride hydrochloride can reduce lubiprostone-related nausea. Methods: Two hundred and thirty-five patients who were receiving lubiprostone (24 μg capsule twice daily) were enrolled. Seventy-one patients took a prophylactic dose of itopride (50 mg tablet twice daily) together with lubiprostone to prevent nausea. Thus, the patients were divided into 2 groups: lubiprostone alone (164; control group) and combination therapy with lubiprostone and itopride (71; itopride group). Efficacy measures included changes in constipation scoring system scores, the incidence of treatment-related adverse events including nausea, and the percentage of patients who discontinued treatment within two weeks after administration. Results: Of the 235 patients who were enrolled, 196 were available for analysis. Both treatment groups experienced statistically significant improvements in constipation scoring system scores. The percentage of patients who reported ≥1 adverse event was significantly higher in the control group (40.9%) than in the itopride group (21.9%). The percentage of patients experiencing nausea was statistically and significantly lower in the itopride group than in the control group (9.4% versus 22.7%). The itopride regimen was also statistically superior compared to the control regimen in terms of treatment discontinuation. Conclusion: The prophylactic administration of itopride can decrease the risk of nausea in patients receiving lubiprostone and consequently reduce the risk of treatment discontinuation.

Infections in Cirrhotics: Types, Microbiological Spectrum and Risk Factors—5-Year Cohort Study

Abstract: Cirrhosis is an immunocompromised state that leads to various infections, with an estimated 30% mortality. Pakistan already has a high morbidity and mortality related to complications of cirrhosis. Where the data on infection among cirrhotics is scanty, this study aimed to determine the frequency, microbiological spectrum and various risk factors of infections in cirrhosis of liver. This is a prospective cohort study conducted at a tertiary care hospital. The microbiological spectrum and frequency of infections was determined in cirrhotics. Various risk factors for infection among cirrhotics were evaluated like upper gastrointestinal bleed, use of proton pump inhibitors, malnutrition and severity of cirrhosis. Out of eleven hundred and forty-one patients with cirrhosis of liver, four hundred and ninety (42.94%) patients had infections. All kinds of infections like peritoneal, respiratory, urinary tract and skin were present in cirrhosis of liver where ascitic fluid infections (AFI) were the commonest i.e. 44.89%. The risk factors for bacterial infections among patients with cirrhosis of liver were upper gastrointestinal bleeding (odd ratio = 4.57, p = 0.0001), use of proton pump inhibitors (odd ratio = 2.57, p = 0.0001), degree of malnutrition (odd ratio = 10.34, p = 0.0001) and severity of cirrhosis (odd ratio = 12.99, p = 0.000). All types of infections occurred with varying frequency in cirrhosis of liver. Upper gastrointestinal bleeding, severity of cirrhosis, use of high dose proton pump inhibitors and severe malnutrition are important risk factors for infections among cirrhotics.

Outcome of patients undergoing early versus late endoscopic intervention for acute oesophageal variceal bleeding at Air Force Hospital, Egypt. A population based cohort study

Abstract: Background: Whether on-call gastroenterologists should perform emergency endoscopic treatment or delay endoscopy the next day has not been investigated. This study aims to investigate the effect of timing of endoscopy on patients with acute esophageal variceal bleeding. Patients and Methods: We included 167 patients with acute variceal bleeding in the gas-troenterology unit of the air force hospital, Cairo, Egypt, from 15 January till 15 July 2010. Endoscopy was scheduled once the patient’s hemodynamics permitted. Time from admission to endoscopy was recorded. Patients were stratified into 2 groups: Early endoscopy: when done ≤ 12 hours and late endoscopy: when done > 12 hours. Patients were followed up for 42 days. Results: The study included 102 males (61.1%) and 65 females (38.9%) (mean age 54 ± 11 years). 151 patients received endoscopic treatment. Early endoscopy group included 85 patients (56.3%), and the late endoscopy group included 66 patients (43.7%) (p = 0.14). Early endoscopy patients were transfused a mean of 2.9 (±1.8) units of blood versus 4.3 (±0.14) units in the late endoscopy patients p = 0.001. Mean hospital stay was 7.1 (±3.3) days versus 9.3 (±4.6) days in the early and late groups respectively p: 0.001. 5-day mortality was reported in 6 (±7) cases in the early endoscopy group and 23 (±34.8) cases in the late endoscopy group p: 0.001. Conclusion: Early endoscopic intervention for patients with acute variceal bleeding is associated with a more favorable outcome in terms of morbidity and mortality. On call gastroenterologists should comply with the 12-hour period rather than delaying cirrhotic patients with acute variceal bleeding to the following day.

The clinical significance of upper gastrointestinal bleeding etiology score in determining variceal bleeding

Abstract: BACKGROUND: Upper gastrointestinal bleeding (UGIB) is a common, and potentially life threatening condition, which can be divided into variceal and non-variceal sources of bleeding. OBJECTIVE: To examine the validity of the upper gastrointestinal bleeding etiology score compared to the current gold standard, the emergency Esophagogastroduodenos-copy (EGD), for determining the etiology of UGIB. METHODOLOGY: 101 patients presenting with upper gastrointestinal bleeding presented in the emergency department of Capital Hospital, Islamabad between February 2010 and March 2012 were in- cluded in this cross-sectional study. The upper gastrointestinal bleeding score was computed for each case by accounting for the clinical parameters of previous diagnosis of cirrhosis or signs of chronic liver disease × 3.1, presence of red vomitus × 1.5, and red N/G aspirate × 1.2. Each parameter was given a score of 1 if present, and 0 if absent, with a total score ≥3.1 favoring variceal bleed, and a score of

Esophageal Perforation in Children: Experience in Kurdistan Center for Gastroenterology and Hepatology/Iraq

Abstract: Background: Esophageal perforation is a rare, but potentially life threatening injury. The etiology and management of this condition have changed overtime. Iatrogenic causes are increasingly recognized and management is evolving towards more conservative approaches. Objective: To review our experience in the management of esophageal perforation in pediatric patients. Patients and methods: This retrospective study was conducted in the Kurdistan center for gastroenterology and hepatology in Sulaimani city. Review of records for cases of esophageal perforation during the period from January 2006 to October 2013 was performed. Results: Ten cases were found to have esophageal perforation. The causes of esophageal perforation were complications of endoscopic dilation for esophageal stricture (n = 7), button battery ingestion (n = 2), complication of esophagoscopy for corrosive injury (n = 1). The mean age was 42 months (range, 18 - 75 months). The diagnosis was made during the procedure in 6 cases, within 12 hours in 2 cases and late in the two cases of battery ingestion. Subcutaneous emphysema and respiratory distress were the main presenting features. The location of perforation was thoracic in 9 cases and cervical in 1 case. Conservative management was successful in 7 patients and surgical closure was done in two patients. One death has been reported. Conclusion: Iatrogenic causes were the most common causes of esophageal perforation. Conservative management with interventions guided by clinical response can have a favorable outcome and may become the best initial treatment strategy in the future. Further larger scale studies are recommended to establish the best protocol for conservative management.

Etiologies of Dyspepsia among a Chinese Population: One Hospital-Based Study

Abstract: Background and Methods: Dyspepsia refers to a collection of upper gastrointestinal symptoms, and the causes may be either organic or functional. The aim of this study was to investigate the etiologies of dyspepsia among a Chinese population in Taiwan. Patients who underwent upper endoscopy for symptoms of dyspepsia were retrospectively analyzed between January and December 2008. Exclusion criteria included cirrhosis with varices, heart-burn sensation as the main symptom, gastrointestinal bleeding, hepatobiliary abnormalities, prior gastric surgery, and use of anti-acid medication for more than 2 months. Patients were classified according to the findings of upper endoscopy. Results: Data from the medical records of 2062 patients were collected and retrospectively analyzed. Normal endoscopic findings, gastritis, gastric ulcers, duodenal ulcers, reflux esophagitis and esophageal or gastric malignancy accounted for 1174 (56.9%), 215 (10.4%), 254 (12.3%), 194 (9.4%), 182 (8.8%) and 43 (2.1%) cases, respectively. The overall ratio of H. pylori infection was 28.4%. The ratio was the highest in duodenal ulcers and the lowest in reflux esophagitis. A significantly higher ratio of patients with gastric ulcers had a history of aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) usage. Conclusion: Patients with organic dyspepsia, compared to those with functional dyspepsia, were older, male, and had a higher H. pylori infection ratio, a positive relationship with aspirin or NSAIDs usage, and more risk factors. These findings demonstrate that upper endoscopy has a high diagnostic yield in patients in this group.

Polymorphisms in methylenetetrahydrofolate reductase gene: Their impact on liver steatosis and fibrosis of chronic hepatitis c patients

Abstract: Aim & Background: The mechanism of steatosis in Hepatitis C virus infection is multifactorial; therefore, it is complex and unclear. The aim of this study was to investigate the effects of methylentetrahydrofolate reductase (MTHFR) gene polymorphisms on the course of chronic hepatitis C virus infection and the development of steatosis due to hepatitis C virus. Methods: This study included 109 patients with chronic hepatitis C virus infection. Necroinflammatory activity, degrees of fibrosis and steatosis and MTHFR gene polymorphisms were investigated. Polymerase chain reaction-restriction fragment length polymorphism was used to determine MTHFR C677T and A1298C polymorphisms. Results: Fibrosis was correlated with age (r = 0.336, p = 0.002), platelet (r = ?0.448, p was a relation between MTHFR C677T and the degree of fibrosis but not A1298C (p = 0.014, p = 0.187 respectively). Conclusion: We found that MTHFR C677T polymorphism contributed to the development of fibrosis in patients with chronic hepatitis C virus infection.

The Expression of VEGF-C and It’s Receptor VEGFR-3 Correlates with Lymph Node Metastasis in Gastric Cancer

Abstract: Background: Regional lymph node invasion and metastasis may happen early during the progres-sion of gastric cancer. The lymphadenectomy is still the key method to treat lymph nodemetastasis. In the recent years, scientists have found some growth factors and receptors that can promote angiogenesis which also play an important role in adjusting the formation of the new lymph vessel, and lymphangiogenesis may play a key role in the process of lymph node metastasis. Objectives: This study aims to explore the correlation between the expression of vascular endothelial growth factor-C (VEGF-C), vascular endothelial growth factor receptor 3 (VEGFR-3) and lymph node me-tastasis (LNM), and its impact on prognosis of patients with gastric cancer. Methods: The samples were collected from gastric cancer database of Sichuan Provincial People’s Hospital from 2005 to 2007, which were registered and followed up. The samples were divided into two groups according to situation whether there is lymph node metastasis, which is lymph node metastasis N(+) and without lymph node metastasis N(﹣). The expression of VEGF-C, VEGFR-3 and CD34 were measured by immuno histochemistry staining with monoclonal antibody (anti-VEGF-C, anti-VEGFR-3, and anti-CD34). Kaplan-meier, logistic and Cox regression was performed to explore their impact on the prognosis of patients with gastric cancer. Results: In total 186 cases were collected, 96 cases in N(+) group and 90 cases in N(﹣) group. The percentage of VEGF-C expression is 54.83% (102/186) in all groups, 73.9% (71/96) in N(+) group, and 34.44% (31/90) in N(﹣) group (p = 0.001). The percentage of VEGFR-3 expression is 33.33% (62/186) in all groups, 44.78% (43/96) in N(+) group, and 21.11% (19/90) in N(﹣) group (p = 0.001). There are no statistical differences in microvessel density (MVD) between N(﹣) and N(+) group. The average lymphatic vessel density (LVD) was significant different between N(+) and N(﹣) group (26.23 ± 8.2 and 18.46 ± 7.4, t = ﹣2.427, p = 0.016). The five-year overall survival rate of N(+) group is 31% and the N(﹣) group is 66%; there are statistical differences between the two groups (Log rank = 27.15, p = 0.001). The five-year overall survival rates of VEGF-C positive group and VEGF-C negative group are 36% and 59%, with the statistical differences (Log rank = 27.15, p = 0.001). And the five-year overall survival rates of VEGFR-3 positive group and VEGFR-3 negative group are 31% and 43%, also with the statistical differences (Log rank = 5.241, p = 0.041). Conclusions: The expressions of VEGF-C, VEGFR-3 in cell plasma of gastric cancer tissue not only correlate with lymphatic vessel density and lymph node metastasis (LNM), but also are important factors which impact prognosis of gastric cancer patients.

Intragastric Balloon (BIB) for the Management of Obesity, Report on the First Egyptian Experience

Abstract: Introduction: The bioenteric balloon (BIB) is widely applied in the management of obesity. Aim of the work: This is a report on the efficacy and safety of BIB® device in the first 101 Egyptian cases. Methods: Patients referred for BIB between January 2011 till December 2012 were evaluated retrospectively. BIB was inserted for 6 months according to predetermined inclusion and exclusion criteria. Results: In 101 cases, 17 cases were males (16.8%) and 84 cases were females (83.2%), mean age 33.2 (±10.44) years, mean BMI 35.9 (±4.65) kg/m2. None of the patients exhibited balloon migration or perforation. The balloon was removed upon request in 3 patients due to exaggerated intolerance (2.9%). The mean weight loss was 15.5 kg (±4.67), mean EWL 64.12% (±23.48%). The mean BMI at extraction was 29.7 kg/m2 (±4.48) with a BMI loss of 6.2 kg/m2 (±2.0). 87 patients (88.7%) achieved target EWL (32.1% of excess weight), and 87 patients lost >12.2% of their basal weight (88.7%). 70 patients achieved BMI loss >5.7 kg/m2 (71.4%). Conclusion: BIB achieves acceptable success with minimal complications. In further long term, prospective studies are needed to evaluate obesity related comorbidities when using such modality and to compare it to other available devices.

Glucose Metabolism Disorders in Cirrhosis: Frequency and Risk Factors in Tunisian Population. Results of a Cross-Sectional Study

Abstract: Background and aims: Alterations in carbohydrate metabolism are frequently observed in cirrhosis; to determine the frequency of diabetes mellitus and impaired glucose tolerance in Tunisian cirrhotic patients and identify risk factors. Patients and methods: Cross-sectional study; fasting plasma glucose levels were measured in consecutive patients with cirrhosis. Oral glucose tolerance test was performed if fasting plasma glucose level was normal. Glucose metabolism disorders were then classified as: impaired glucose tolerance and diabetes mellitus. Cirrhotics with glucose metabolism disorder were compared to those without. Results: Seventy-seven patients with cirrhosis were included: 68.8% were diagnosed as having glucose metabolism disorder; diabetes in 42.8% and impaired glucose tolerance in 26%. The tests were able to identify 60.4% of glucose metabolism disorders. Univariate analysis disclosed a higher proportion of female gender (p = 0.04) and more frequent familial history of diabetes mellitus (p = 0.005) in the group with glucose metabolism disorder. There were no statistically differences regarding age, etiology and severity of the cirrhosis, and dry body mass index. Multivariate analysis showed that familial history of diabetes was the only independent risk factor (OR = 5.1, p = 0.005). Conclusion: In our study, the frequency of glucose metabolism disorders was 68.8%. Oral glucose tolerance test allowed disclosing nearly half of them, pointing a high incidence of latent glucose metabolism disorders. In this way, it should be routinely evaluated in all patients with cirrhosis. Familial history of diabetes was the only independent risk factor, suggesting that other factors in addition to liver disease may play a role.

Prevalence of Heartburn in Abidjan, a Black African Country, and Associated Factors

Abstract: Aims: To determine the prevalence and risk factors of heartburn in Abidjan, a black African city. Patients and Methods: cross-sectional study from June 15 to September 30, 2003. One thousand nine hundred forty (1940) persons from five health zones of the city Abidjan were included after their informed consent. Socio demographic and clinical parameters were collected using a questionnaire in an interview format. Heartburn was defined as a discomfort or burning sensation extending from the sternal manubrium to the base of the neck. Factors related to the complaint were asked such as predisposing factors, habits (tobacco, alcohol and coffee intake) and body mass index. Stepwise multiple logistic regression analyses were used to examine associations between these factors and heartburn. Results: Among 1940 respondents (mean age 28 ± 9 years; sex ratio (M:F) 0.86), heartburn occurred in 433 persons (once a week in 9.2% of case (178 persons)). Five factors were statistically associated with heartburn: male sex (p = 0.025, OR = 0.555 [CI95% 0.331 - 0.930]), heartburn in a family member (p = 0.010, OR = 1.765 [95%CI 1.143 - 2.725]), constipation (p = 0.011, OR = 2.182 [95%CI 11,953,983]), right lateral decubitus (p = 0.001, OR = 6.247 [95%CI 2.079 - 18.775]) and after a meal (p = 0.000, OR = 2.643 [95%CI 1.594 4.383]). Conclusion: Heartburn is common in this black African population. Male sex appears to be less associated. Constipation, right lateral decubitus and after a meal are trigger factors for heartburn. Heartburn in a family member is a risk factor.

Aquaporin 8 mRNA expression after intestinal resection in rat

Abstract: Backgrounds: Aquaporins (AQPs), the mammalian water channels, have been localized in various organs, including the gastrointestinal (GI) tract. We examined AQPs expression in rat models of massive intestineal resection to determine the functions of AQPs in the GI tract. Methods: Female Sprague-Dawley rats (n = 15) underwent 90% resection of the small intestine, and Female Wistar-Kyoto rats (n = 10), received subtotal colectomy, and were sacrificed following the operations. RNase protection assay and quantitative reverse transcription-polymerase chain reaction (RT-PCR) were performed to measure the AQPs mRNA expression in the GI tract. Immunohistochemistry was performed to confirm AQP8 protein expression. Results: AQP8 mRNA expression (mean ± standard error), was enhanced in the jejunum of the short bowel rats at days 7 and 14 (37.6% ± 1.4% and 18.5% ± 2.4%, respectively, p