Pancreatitis after endoscopic retrograde cholangiopancreatography in a patient with normal serum amylase level

Endoscopic retrograde cholangiopancreatography [ERCP] can be mentioned as the most complex endoscopic procedure and is widely used for diagnosis and treatment of biliary and pancreatic diseases. Pancreatitis is the most common complication following ERCP, which may be life threatening. This article presents an old woman diagnosed as having post-ERCP pancreatitis without increasing in serum amylase level. A 69-year-old woman with a history of cholecystectomy a few years earlier, was presented with abdominal pain in epigastric region. Abdominal sonography revealed a dilated common bile duct [[CBD], 11 mm in diameter]] so MRCP [Magnetic Resonance Cholangiopancreatography] was performed for diagnosis. There were several stones in CBD, so the patient underwent therapeutic ERCP. Six hours after the procedure, she complained of severe abdominal pain in the right upper quadrant [RUQ] and tenderness. Serum amylase was 51 mg/dL. An abdominal computed tomography revealed pancreatitis

Pancreatitis is the most common complication after ERCP, which presents with abdominal pain in the RUQ and increase in serum amylase level more than 3 fold of normal upper limit. In this case, pancreatitis occurred without laboratory findings consistent with the diagnosis, which is not a common occurrence

A high serum-ascites albumin gradient and mediastinal fibrosarcoma

Accumulation of free fluid in the peritoneal cavity is called ascites. The first step in identifying its etiology is to determine the serum-ascites albumin gradient [SAAG]. According to this parameter, a high SAAG is regarded as a gradient greater than 1.1 g/dL. This condition has some differential diagnoses such as liver cirrhosis, Budd-Chiari syndrome, heart failure, and idiopathic portal fibrosis. In the present article, we present a young man with abdominal distention due to a high SAAG. Further evaluation of the abdominal and thoracic cavity revealed a mass in the posterior mediastinum, which had compressed the inferior vena cava and left atrium and led to Budd-Chiari syndrome. Evaluation of the biopsy sample showed fibrosarcoma. Mediastinal fibrosarcomas, though rare, should be considered in the differential diagnosis of mediastinal masses

Mesalazine has no effect on mucosal immune biomarkers in patients with diarrhea-dominant irritable bowel syndrome referred to Shariati Hospital: a randomized double-blind, placebo-controlled trial

Intestinal mast cells may cause gastrointestinal symptoms in patients with diarrhea-dominant irritable bowel syndrome [IBS]. The objective of this study was to determine the effect of mesalazine on the number of lamina propria mast cells and clinical manifestations of patients with diarrhea-dominant IBS referred to Shariati Hospital affiliated to Tehran University of Medical Sciences

Methods: This was a randomized placebo-controlled double-blind trial conducted on 49 patients with diarrhea-dominant IBS. The patients were randomly assigned to one of the experiment or control groups. The patients in experiment group took 2400 mg mesalazine daily in three divided doses for 8 weeks and the patient in control group took placebo on the same basis. Our first targeted outcome was an assigned downturn of mast cells number to the safe colonic baseline and the next one was a marked palliation of disease symptoms. Data were analyzed conforming intention-to-treat method. We used MANCOVA test to compare our both assigned outcomes in the two groups. We also compared the data with baseline values in both groups. All statistical tests were performed at the significance level of 0.05

Results: There was no significant difference between Mesalazine and placebo groups regarding the number of mast cells [p value=0.396], abdominal pain [p value=0.054], bloating [p value=0.365], defecation urgency [p value=0.212], and defecation frequency [p value=0.702]

Conclusion: Mesalazine had no significant effect either on the number of mast cells or on the severity of disease symptoms. This finding seems to be inconsistent with the hypothesis indicating immune mechanisms as potential therapeutic targets in IBS. The possible difference in this effect of Mesalazine should be evaluated in further studies among populations varying in race, ethnic, and geographical characteristics

[Esophageal perforation due to swallowing a glass body]

Esophageal perforation is a rare yet very serious condition, which usually needs surgical repair. In spite of its rarity, esophageal perforation could become extremely dangerous and even life-threatening. Therefore it needs immediate surgical intervention. The first symptom to appear is pain. Perforation in the middle and lower third of the esophagus might as well cause difficulty in swallowing, dyspnea, and chest pain. A 61-year-old man presented to the Emergency Room due to sensation of a foreign body and epigastric pain after meal for which he underwent upper endoscopy. The foreign body was seen in the lower third of the esophagus. Considering the bilateral penetration of the sharp foreign body to the esophageal wall, no effort was made to bring the foreign body out. The patient underwent computed tomography [CT] without contrast, which showed right posterolateral mediastinal air leakage and slight pleural effusion in the right hemithorax. As recommended by thoracic surgeon, instead of thoracotomy, the foreign body was brought out in the operating room by endoscopy [under preparation in order to convert the procedure to thoracotomy if needed]. After the procedure, a CT with oral contrast was done, which showed free air and leakage of contrast to the right posterolateral hemithorax as well as an increase in the pleural effusion. Normal saline was immediately injected to both sides of the perforation site by endoscopy in order to prevent further leakage. The patient was observed by both surgery and gastroenterology teams for a week to undergo thoracotomy in case he develops mediastinitis. After a week, he underwent Gastrografin swallow and then Barium swallow. The patient was discharged from the hospital because no evidence of remaining perforation or any microperforations were seen. Esophageal perforation is a surgical emergency usually happening due to diagnostic and pass through esophagous to go to the therapeutic actions. Most swallowed foreign bodies stomach, but sharp objects may cause perforation in esophagus. Foreign bodies mostly get trapped in the physiologic constrictions. Dysphagia and odynophagia are subcutanneous common symptoms of foreign body invasion in to the esophagous. Emphysema is a diagnostic key for the matter of esophageal perforation. Treatment for such condition differs among various patients

Efficacy of common bile duct stenting for large stones

Background: common bile duct [CBD] stones exist among 12% of patients with cholelithiasis. They may result in some complications including pancreatitis and cholangitis. The common therapeutical method is endoscopic sphincterotomy during ERCP[Endoscopic Retrograde Cholangio-Pancreatography] and stones removal. This method does not have a reasonable success rate for stones with a diameter larger than 15 mm and may cause serious complications. The aim of this study was to evaluate the CBD stenting method in the treatment of large CBD stones

Materials and Methods: this study was performed on 32 patients who presented to the ERCP unit of Shahid Beheshti hospital in Qom with large CBD stones. Success rate in CBD clearing and rate of some complications including rupture of CBD, pancreatitis, and cholangitis were evaluated after the first ERCP for stent replacement, and the second for its removal

Results: the success rate in complete CBD clearing was 93.8%. A reduction in size and number of stones was seen during a 2-month period, which was statistically significant. No case of CBD rupture and cholangitis was detected and the incidence of pancreatitis was 18.8%

Conclusion: CBD stenting has a reasonable success rate for reducing the size and number of CBD stones

Nonadherence to medication in inflammatory bowel disease: rate and reasons

Background: This study is the first study to evaluate the nonadherence rate and reasons of same patient with inflammatory bowel disease [IBD] in Iran

Method: During 9 months, 500 patients with IBD were enrolled in the study. Patients were interviewed about their nonadherence behaviors. Factor analysis was used to analyze the collected answers

Results: The overall rate of nonadherence was 33.3% [27.6% intentional nonadherence and 5.7% unintentional nonadherence]. 33.6% of the patients had at least one relapse after discontinuing treatment. The most frequent reason for intentional nonadherence was discontinuing the treatment after recovering from symptoms [42.7%]. The most frequent reason for unintentional nonadherence was forgetfulness [5.2%]. 19.8% of the patients did not visit their gastroenterologist on time and they purchased drugs from the drugstore. These patients reported that their clinics were too far and difficult to access. There was no significant relationship between nonadherence and demographic variables

Conclusion: Multiple reasons are suggested as factors of medication nonadherence and they seem to be different among different populations. Determining these possible reasons, could lead to finding suitable strategies to overcome or reduce them