Anastomotic biliary stricture following liver transplantation and management analysis: 15 years of experience at a high-volume transplant center.

INTRODUCTION: The occurrence of anastomotic biliary stricture (BS) remains an essential issue following liver transplantation (LT). The present study aimed to compare our findings regarding the incidence of anastomotic BS to what is known. METHODS: The present study is a single-center, retrospective cohort study of a total number of 717 consecutive patients (426 men and 291 women) who had undergone LT from January 2001 to March 2016. Multivariable Cox regression analysis was conducted to evaluate the risk factors associated with anastomotic BS development. RESULTS: Post-transplant anastomotic BS developed in 70 patients (9.8%). In the Cox multivariate analysis (a stepwise forward conditional method), factors including biliary leak (hazard ratio [HR]: 6.61, 95% confidence interval [CI]: 3.08-17.58, p < 0.001), hepatic artery thrombosis (HR: 2.29, 95% CI: 1.03-5.88; p = 0.003), and acute rejection (HR: 2.18, 95% CI: 1.16-3.37; p = 0.006) were identified as independent risk factors for the development of anastomotic BS. Surgery in 6 cases (66.7%), followed by endoscopic retrograde cholangiopancreatography (ECRP) with a metal stent in 18 cases (62.1%), percutaneous transhepatic biliary drainage in 9 (20.9%), and ERCP with a single plastic stent in 8 (18.2%), had the highest effectiveness rates in the management of BS, respectively. CONCLUSIONS: Risk factors including biliary leak, hepatic artery thrombosis, and acute rejection were independently associated with an anastomotic BS. ERCP with a metal stent may be considered as an effective treatment procedure with a relatively low complication rate in the management of benign post-LT anastomotic BS.

Comparing the efficacy and complications of Endoscopic Biliary Drainage (EBD) and Percutaneous Transhepatic Biliary Drainage (PTBD) in patients with perihilar cholangiocarcinoma.

Introduction and Objective: Hilar cholangiocarcinoma (HCCA) is a rare malignancy in patients with biliary disease. If jaundice and obstruction before surgery are left untreated, then they can cause side effects such as cholangitis, delayed tumor treatment, decreased quality of life, and increased mortality. Surgery is the main treatment for HCCA. Therefore, this study was performed to compare the efficacy and complications of percutaneous transhepatic biliary drainage (PTBD) and endoscopic biliary drainage (EBD). Methods: This cohort study was conducted on 20 patients with biliary obstruction who had been selected by simple random sampling and divided into two groups of EBD and PTBD. Three weeks after surgery, patients were compared in terms of bilirubin levels and postoperative complications. Data were analyzed by descriptive statistics (table, mean, and standard deviation) and inferential statistics (independent t-test, Chi-square test, and Fisher's test). Results: Independent t-test did not show a significant difference between the two groups in terms of bilirubin level (P = 0.77). However, despite a decrease in bilirubin level in both groups, independent t-test showed that this difference was not significant (P = 0.08). Fisher's exact test showed a significant difference between the two groups in terms of postoperative complications (P = 0.02). Conclusion: Using both drainage methods before surgery reduced bilirubin levels in patients, but EBD method had fewer side effects than PTBD method. The EBD method was performed under the direct supervision of a gastroenterologist. In performing this procedure, specialist physicians should have more supervision.

Differentiation of Crohn's disease and ulcerative colitis using intestinal wall thickness of the colon: A Diagnostic accuracy study of endoscopic ultrasonography.

Background: The differentiation between Ulcerative Colitis (UC) and Crohn's Disease (CD) is an important issue for choosing the appropriate treatment. Endoscopic Ultrasonography (EUS) has been used to distinguish different layers of the gastrointestinal wall. We performed this study to evaluate the accuracy of EUS in differentiating colonic UC from CD compared to standard tests (colonoscopy, pathology, imaging, and clinical presentation). Methods: This is a prospective, single-blinded diagnostic accuracy study, on 70 patients (30 UC, 30 CD, and 10 healthy controls). After obtaining informed consent, patients underwent a complete workup and were referred to an endosonographist who was blind to the diagnosis. The thickness of mucosa, submucosa and the total wall (TWT) of mid-sigmoid colon were measured by Pentax radial echoendoscope EPKI-7000 with Avius Hitachi ultrasound system (Japan). Statistical analyses were performed using the SPSS statistical software (v23). Statistical significance was considered if P-values were less than 0.05. Results: Our study revealed a sensitivity of 100% (90.7-100%) and specificity of 90.9% (70.8-98.8%) for EUS to differentiate UC and CD compared to standard diagnostic tests. Mean mucosal thickness in patients with UC was significantly greater than patients with CD, while, the mean sub-mucosal thickness was significantly greater in patients with CD (p<0.001). The sensitivity and specificity of mean mucosal thickness for differentiating UC from CD and controls were 92.3% and 88.6% with a cut-off point of 1.1 mm (p<0.001). Moreover, sensitivity and specificity of mean submucosal thickness for differentiating CD from UC and controls were 100% and 86.1% with a cut-off point of 1.08 mm (p<0.001). Conclusion: EUS can be used as an efficient modality with acceptable accuracy to differentiate Crohn's disease and Ulcerative Colitis and to determine disease activity.

Case series of papillectomy by endoscopic retrograde cholangiopancreatography (ERCP).

Ampullary neoplasms are one of the causes of obstructive jaundice. Endoscopic retrograde cholangiopancreatography (ERCP) is useful procedure for diagnosing and tissue sampling of ampullary neoplasms. Ampullectomy by resecting entire ampulla provides whole lesion for pathologic evaluation and also is appropriate for real pathologic staging for further management decision but ampullectomy considered as a heroic endoscopic procedure. We share our experience in this field and explain our results.

Hepatic Artery Pseudoaneurysm; Simple or Difficult to Diagnose?

Ruptured hepatic artery pseudoaneurysm (HAP) generally leads to the hemobilia and can be diagnosed by endoscopy. This condition mostly occurs after an iatrogenic trauma. The management of the HAP is still a big challenge. Due to an increased rate of HAP cases over the last decade, appropriate management is necessary for the optimal outcomes achievement. Here, we report a 59-year-old woman presenting with hematemesis, melena, hematochezia, and epigastric pain. The CT scan of the abdomen showed intrahepatic biliay dilation with hypodense material, probably a clot inside it. Subsequently, the patient was transferred to an angiography unit. Celiac artery angiography demonstrated a right hepatic artery pseudoaneurysm, which subsequently embolized.

Bone mineral density in hemophilia patients.

Patients with hemophilia suffer from low bone mineral density (BMD) due to several risk factors including arthropathy and resulting immobility. Recent studies have shown variable frequency of low BMD in this group of patients. This study attempts to assess the prevalence of low BMD (osteoporosis and osteopenia) and the associated risk factors in a group of Iranian hemophilia patients. Patients with moderate or severe hemophilia underwent BMD measurement by dual energy X-ray absorptiometry. The results were correlated with other variables including physical activity, calcium intake and demographic data. Forty two patients with the mean age of 31 years (range 18-72) completed the study. The prevalence of osteoporosis in the spine and the left femoral neck was 23.8 and 14.6 %, respectively, and osteopenia in the spine and femoral neck was seen in 45.2 and 31.7 % of the patients, respectively based on the WHO T-score criteria. We found only cigarette smoking to be significantly related to low BMD (P < 0.001). There were two cases of pathologic fracture at femoral neck and forearm (4.8 %). Low BMD is very common in patients with hemophilia. Appropriate assessment of BMD and control of predisposing factors such as prophylactic factor replacement (to prevent hemarthrosis) and cessation of cigarette smoking are warranted.

Pseudoachalasia: a diagnostic challenge.

Here, we present a case of a 78-year-old man that underwent gastrointestinal endoscopy because of one- month history of dysphagia to liquids and solid foods with accompanying weight loss. On endoscopy, there was distal esophageal stenosis. Multiple biopsies were obtained. Histologic examination of the samples revealed normal tissue. The stenosis was treated by dilatation and abdomino pelvic computed tomography scanning was performed to search for an underlying malignant lesion that showed a mass adjacent to distal esophagus. We did endosonography- guided fine needle aspiration of the mass. It was a squamous cell carcinoma (SCC). Malignancy is a challenging diagnosis in patients with dysphagia and near normal endoscopy. To our knowledge, there are a few reports of SCC to cause it.

Double-balloon Enteroscopy: The results of a new experience in Iran.

BACKGROUND: Approach to the small intestine has been difficult even with newer methods. Double-balloon enteroscopy (DBE) has been created for diagnostic and therapeutic interventions in diseases of the small intestine. Small intestinal diseases have different etiologies in each country. The DBE has been introduced in recent years in Iran. Our aim was to study the indications and results of DBE in some academic centers in Iran. METHODS: Fifty-five patients with symptoms and signs related to small intestine without definitive diagnosis but with previous workup were enrolled in the study. The DBE was performed in three different medical universities in Iran. RESULTS: The mean age of the patients that underwent the DBE was 47.2 ± 17.3 years. Abdominal pain (54.5%) and occult gastrointestinal bleeding (23.6%) were the most common presentations. Small bowel lesions were detected in 26 patients (47.3%); the most common lesions were ulcer (46.2%) and polyps (19.2%). Crohn's disease (12.7%) was the commonest diagnosis found in DBE procedure. Patients presenting with abdominal pain orl ower hemoglobin level were more likely to be diagnosed (both p≤ 0.05). Small intestinal diseases were ultimately diagnosed in 47.3% of the patients. Twenty percent of the patients had another disease outside the small bowel. CONCLUSIONS: DBE is an effective and relatively safe diagnostic and therapeutic option for small bowel evaluations. Accurate selection of patients and more experience technicians and physicians will improve the efficacy of this procedure in Iran.

Reflux esophagitis in war-related sulfur mustard lung disease.

UNLABELLED: Background Sulfur mustard (SM) has acute and chronic effects on skin and mucosal surfaces. The aim of the study was to evaluate the frequency of esophagitis in a historical cohort of veterans who had been exposed to SM in Iran-Iraq war nearly 25 years ago. METHODS: One hundred two veterans with dyspepsia and/or heartburn underwent esophago-gastroduodenoscopy. Of them, 52 cases had been exposed to SM and had chronic mustard lung disease. Controls included 50 veterans without SM exposure. Esophagitis was defined according to standard criteria. RESULTS: 81.6% of cases and 70.6% of controls had heart burn and/or regurgitation (p= 0.224). Esophagitis was seen in 40% of cases and 26.5% of controls (p= 0.155). CONCLUSION: Based on our findings, SM exposure seems not to be associated with increased esophagitis.

Accuracy of pepsinogens for early diagnosis of atrophic gastritis and gastric cancer in Iranian population.

BACKGROUND: Currently, non-invasive methods for screening atrophic gastritis and gastric cancer are lacking. The purpose of this study was to evaluate the value of serological parameters including serum pepsinogen I (PGI), pepsinogen II (PGII) and pepsinogen I: II ratio for the screening atrophic gastritis and gastric cancer. METHODS: The study population consisted of 132 dyspeptic patients who had undergone upper endoscopy with biopsy. Blood samples for ELISA assays of serum PGI, PGII and IgG antibodies against Helicobacter pylori were drawn. Comparison between the two groups was done by Student's t- test, and Mann Whitney test. Cut-off points were calculated using receiver operating curves (ROC). RESULTS: Mean (±SD) age of the study population was 51.4 (±15.5) years. Values of PGI and PG ratio decreased significantly in the atrophic gastritis as compared with the control group (p<0.05). Values of PG and PG ratio didn't show any significant difference between the gastric cancer and control group (p>0.05). For patients with atrophic gastritis, the area under the ROC for PGI was 0.639 (95% CI:0.538-0.741, p=0.008) in which the best cut-off value was 40µg/L (sensitivity 90%, specificity 67%, accuracy 69%, negative predictive value 92%, YI : 0.429). The area under the ROC for PG ratio was 0.711 (95% CI: 0.617-0.806, p=0.0001) and the best cut-off value was 8 (sensitivity 71%, specificity 71%, accuracy 71%, negative predictive value 86%,YI : 0.431). CONCLUSION: It seems that PGI, PGI: PGII ratio is potential biomarkers for screening atrophic gastritis with high sensitivity, specificity, accuracy and negative predictive value. Serology could be used as a screening method for the detection of precancerous states due to its convenience, relative low cost and safety.

Acquired factor V inhibitor developing in a patient with esophageal squamous cell carcinoma.

An 82-year-old man referred to our medical ward because of epistaxis and melena was found to have 12 Bethesda units of factor V inhibitor. He was managed for bleeding with supportive care, followed by corticosteroid therapy. The bleeding completely stopped 1 week after corticosteroid therapy. Medical history revealed dysphagia during the past 6 months and further evaluation brought to light a squamous cell carcinoma (SCC) in the esophagus. This is the first case of an acquired factor V inhibitor developing in a patient with esophageal SCC without any other risk factors such as surgery.

Hepatitis B knowledge among Iranian adolescents: a national survey.

BACKGROUND: Hepatitis B is the most prevalent chronic infectious liver disease worldwide with serious sequelae. Prevention of the infection can be provided by universal vaccination and improvement in knowledge and behavior about disease transmission. Provision of any educational program requires inquiry about target group baseline knowledge. OBJECTIVES: The aim of this study was to assess Iranian adolescents' knowledge about hepatitis B (HBV) and associated factors. PATIENTS AND METHODS: We conducted a questionnaire-based national survey of 18-year-old adolescents according to stratified cluster random sampling in Iran during 2007. RESULTS: Response rate was 87%. Most adolescents (60%) knew that HBV infects the liver. Percentage of adolescents who gave correct answers to major routes of HBV transmission were as follows: spouse of an infected person 59%, multi-partners 66%, intravenous drug use 73%, body piercing 55% and personal belongings 55%. Higher levels of education, living in rural areas, marriage and (except for body piercing) female gender were associated with better knowledge. The knowledge of HBV infected individuals about major routes of HBV transmission was low (P < 0.001). CONCLUSIONS: There are important deficits in adolescents' knowledge about HBV that requires attention of health educators to tailor educational programs for specific groups.

The views of general practitioners in Iran about prevention and health promotion and related obstacles in clinical practice.

AIM: To explore the awareness and attitudes of Iranian GPs in implementing evidence-based health promotion and disease prevention recommendations in primary care and to describe GPs' perceived barriers to implementing these recommendations. METHODS: Our survey was carried out in 2007 in a random sample of GPs listed from an educational symposiums held for general practitioners. We developed and pre-tested a questionnaire, it was piloted with 417 GPs in general practitioners educational symposiums attending all parts of Iran. Those who did not respond received follow-up mailings and/or telephone calls. Our data management center started data entry and analyzing as soon as the questionnaires were sent back. Discrete variables were expressed as percentages and were compared with the chi-square test or Fisher's exact test as appropriate. Continuous variables were compared by means of the unpaired, two-sided t test. All statistical analyses were performed using SPSS software Version 13. Statistical significance was accepted for P<0.05. RESULTS: Four hundred and seventeen GPs participated in the study. Although they believe they should advise preventive and health promotion activities, in practice, they are less likely to do so. The two most important barriers reported were weak patients' interest in screening tests no reimbursement for GPs. Associations between personal health behaviour and attitudes to health promotion or activities in prevention were found. GPs who exercised felt that they were more effective in helping patients to practice regular physical exercise than sedentary GPs. (P<0.001). CONCLUSION: Significant gaps between GP's knowledge and practices persist in the use of evidence-based recommendations for health promotion and disease prevention in primary care.

Neuropathy caused by B12 deficiency in a patient with ileal tuberculosis: a case report.

INTRODUCTION: Vitamin B12 deficiency can result in macrocytic anemia. Neurologic abnormalities of B12 deficiency include sensory deficits, loss of deep tendon reflexes, movement disorders, neuropsychiatric changes and seizures. Segmental involvement of the distal ileum, such as in tuberculosis, can cause vitamin B12 deficiency. To our knowledge, macrocytic anemia with unusual manifestations such as brain atrophy and seizures due to intestinal tuberculosis has not been reported in the literature. CASE PRESENTATION: A 14-year-old girl presented with complaints of paraplegia, ataxia, fever and fatigue that had started a few months earlier and which had been getting worse in the last three weeks. Her laboratory results were indicative of macrocytic anemia with a serum B12 level <100 (normal, 160-970) pg/ml and hypersegmented neutrophils. Her MRI findings showed brain atrophy. Her fever workup eventually led to the diagnosis of tuberculosis which was documented by bone marrow aspiration smear & culture. A small bowel series showed that tuberculosis had typically involved the terminal ileum which had resulted in vitamin B12 deficiency. She was treated for vitamin B12 deficiency and tuberculosis. Her fever ceased and her hemoglobin level returned to normal. At present, she can eat, write, and speak normally as well as walk and ride a bicycle. CONCLUSION: Vitamin B12 deficiency should be considered in patients with neurologic features such as paresthesia, sensory deficits, urinary incontinence, dysarthria, and ataxia. The underlying cause of B12 deficiency should be determined and treated to obviate the patients' need for long term vitamin B12 therapy.