A randomized trial of rectal indomethacin and sublingual nitrates to prevent post-ERCP pancreatitis.

OBJECTIVES: Acute pancreatitis is the most common adverse event of endoscopic retrograde cholangiopancreatography (ERCP). Recent data suggest that indomethacin can reduce the risk of post-ERCP pancreatitis (PEP) in high-risk individuals. However, whether the combination of indomethacin and sublingual nitrates is superior to indomethacin alone is unknown. Therefore, we aimed to evaluate the efficacy of rectally administered indomethacin plus sublingual nitrate compared with indomethacin alone to prevent PEP. METHODS: During a 17-month period, all eligible patients who underwent ERCP were enrolled in this study. We excluded patients who had undergone a prior endoscopic sphincterotomy. In a double-blind controlled randomized trial, patients received a suppository containing 100 mg of indomethacin, plus 5 mg of sublingual nitrate (group A), or a suppository containing 100 mg of indomethacin, plus sublingual placebo (group B), before ERCP. Serum amylase levels and clinically pertinent evaluations were measured in all patients after ERCP. RESULTS: Of the 300 enrolled patients, 150 received indomethacin plus nitrate. Thirty-three patients developed pancreatitis: 10 (6.7%) in group A and 23 (15.3%) in group B (P=0.016, risk ratio=0.39, 95% confidence intervals (CI): 0.18-0.86). More than 80% of the patients were at high risk of developing pancreatitis after ERCP. Absolute risk reduction, relative risk reduction, and number needed to treat for the prevention of PEP were 8.6% (95% CI: 4.7-14.5), 56.2% (95% CI: 50.6-60.8), and 12 (95% CI: 7-22), respectively. CONCLUSIONS: Combination of rectal indomethacin and sublingual nitrate given before ERCP was significantly more likely to reduce the incidence of PEP than indomethacin suppository alone. Multicenter trials to confirm these promising findings are needed.

Prevalence and risk factors of gastroesophageal reflux disease in Iran: A cross-sectional analysis from the PERSIAN cohort.

BACKGROUND: This study assessed the prevalence of gastroesophageal reflux disease (GERD) in a general adult population in Iran. The association between GERD and various factors was also evaluated. METHODS: We performed a cross-sectional study on 163,018 individuals aged over 35 who were enrolled in the PERSIAN cohort. GERD was defined as the occurrence of heartburn and/or regurgitation symptoms at least several days a month. Survey design analysis for pooled data was performed and multiple regression analysis was conducted to determine the independent risk factors for GERD. RESULTS: The prevalence of GERD in our study was estimated at 21.86% (95% confidence interval:17.4%-36.4%). The mean age of the participants was 49.84 years±9.25 (35-70) and 44.75% of the participants were male. Symptoms of heartburn and regurgitation were reported in 18.65% (n: 29,170) and 6.06% (n: 9,717) of participants, respectively. In the multivariate analysis, several factors were found to be associated with a higher prevalence of GERD: female sex, age >50, current smoking, opium use, weekly consumption of fried foods, frequent consumption of hot tea, less than 6 hours of sleep per night, psychiatric disorders, usage of NSAIDs, and poor oral hygiene, were associated with a higher prevalence of GERD. Conversely, higher education levels and average physical activity were found to be less commonly associated with GERD. CONCLUSION: We found a relatively high prevalence of GERD (21.86%) in this population-based study in Iran. By identifying modifiable risk factors, this research offers opportunities for targeted interventions and lifestyle modifications to reduce the burden of GERD.

Peptic ulcer bleeding: is Helicobacter pylori a risk factor in an endemic area?

BACKGROUND/OBJECTIVE: A high prevalence of Helicobacter pylori infection has been reported in Iran. Although the importance of H. pylori in the induction of peptic ulcer disease is clearly defined, only few studies have addressed its role in bleeding from peptic ulcers. We evaluated the role of H. pylori in peptic ulcer bleeding. METHODS: Patients with acute peptic ulcer bleeding (PUB) and those with peptic ulcer disease without bleeding ('controls') were enrolled. Upper GI endoscopy and rapid urease test were performed in both groups. Histological study for detection of H. pylori was performed in patients with active bleeding, if RUT was negative. Other variables evaluated included sex, age, smoking, previous history of bleeding, non-steroidal anti-inflammatory drugs use, ulcer size, ulcer location, and duration of acid-peptic disease. Multivariate logistic regression analysis was performed to identify independent risk factors. RESULTS: 161 patients with PUB and 287 control patients were enrolled. H. pylori infection was seen more frequently in patients with duodenal ulcer than gastric ulcer (88.9% vs. 60.5%, p< 0.001). Univariate analysis showed that patients with PUB were more often male, older in age, used NSAID, had history of PUB in the past, had ulcer located in the stomach and not in the duodenum, and more often had large ulcer (>1 cm). Logistic regression analysis showed that H. pylori infection was protective in PUB after controlling for confounders (OR 0.41, 95% CI 0.21-0.79), when ulcer location was not entered in the model. A second model including ulcer location (to test for a residual effect) showed that H. pylori infection was not a significant risk factor in PUB (OR 0.61, 95% CI 0.30-1.24). CONCLUSIONS: H. pylori may not be an independent factor in bleeding from peptic ulcers. The lower frequency of this infection in these patients can be described by the higher frequency of bleeding from gastric ulcers, which are less H. pylori related compared with duodenal ulcer.

Prevalence of intestinal parasitic infections and their relation with socio-economic factors and hygienic habits in Tehran primary school students.

School age children carry the heaviest burden of morbidity due to intestinal parasitic infections. Our objective was to determine the prevalence of these infections in primary school children living in Tehran and their association with socio-economic factors and hygienic habits. In September 1998, a total of 19,213 subjects were invited to participate. Data on health and socio-economic status and health-related behaviours, collected via questionnaires, physical examinations and stool sample analyses, were available for 19,209 persons, with a participation rate greater than 99.99%. All participants were subjected to three methods of microscopic examinations on the stool sample and an adhesive cellophane tape slide evaluation. The prevalence rate of intestinal parasitic infection among the students was 18.4%. Coinfection with two or three parasites was seen in 2%. With increase in educational level of parents (especially mothers), the infection rate of children was decreased. Girls showed a significantly higher positive rate than boys. Using piped water, correct method of washing vegetables and increase in the economic score of the family, resulted in a decrease in the infection rate. According to the results, low level of education and consequently poor socio-economic and hygienic condition of families appear to be powerful determinants of infection.

Healthy ranges of serum alanine aminotransferase levels in Iranian blood donors.

AIM: The healthy ranges for serum alanine aminotransferase (ALT) levels are less well studied. The aim of this study was to define the upper limit of normal (ULN) for serum ALT levels, and to assess factors associated with serum ALT activity in apparently healthy blood donors. METHODS: A total of 1,939 blood donors were included. ALT measurements were performed for all cases using the same laboratory method. Healthy ranges for ALT levels were computed from the population at the lowest risk for liver disease. Univariate and multivariate analyses were performed to evaluate associations between clinical factors and ALT levels. RESULTS: Serum ALT activity was independently associated with body mass index (BMI) and male gender, but not associated with age. Association of ALT with BMI was more prominent in males than in females. Upper limit of normal for non-overweight women (BMI of less than 25) was 34 U/L, and for non-overweight men was 40 U/L. CONCLUSION: Serum ALT is strongly associated with sex and BMI. The normal range of ALT should be defined for male and female separately.

Role of endoscopic ultrasonography in prevention of unnecessary endoscopic retrograde cholangiopancreatography: a prospective study of 150 patients.

OBJECTIVE: The purpose of this study was to evaluate the impact of substituting endoscopic ultrasonography (EUS) for endoscopic retrograde cholangiopancreatography (ERCP) in cases of a low to intermediate risk for choledocholithiasis. METHODS: During a 16-month period, patients who were referred for suspected choledocholithiasis, biliary colic, or acute biliary pancreatitis on the basis of alterations in liver enzyme values with or without gallstones seen on transabdominal ultrasonography were included. Endoscopic ultrasonography was performed for all patients. Patients with common bile duct stones underwent ERCP. Cholecystectomy was recommended in all patients with symptomatic gallstones. Cases were followed for 12 months. RESULTS: A total of 150 patients were included. Choledocholithiasis was diagnosed by EUS in 39 patients (26.0%) and was confirmed by ERCP in 30 (77.0%). Fifty-one patients had a normal common bile duct, and follow-up for 12 months showed no abnormalities except in 1 patient. Cholecystectomy without ERCP was recommended for the remaining 60 patients who had symptomatic gallstones or sludge. Endoscopic retrograde cholangiopancreatography was avoided by this approach in 110 patients (73.3%). CONCLUSIONS: In a low to intermediate risk for choledocholithiasis, EUS can preclude the need for ERCP in most cases.