Occult bleeding from a false-in-true non-Meckelian ileal diverticulum.

Ileal diverticula can be congenital or acquired and are rare even among the already rare entity of small bowel diverticula. What has never been reported, as far as we know, is false diverticula arising within the true non-Meckelian diverticulum with mesenteric erosion causing an occult gastrointestinal bleed. We present a patient with occult gastrointestinal bleeding from a false-in-true ileal diverticulum. Multiple investigations were required to localise the bleeding site after which the patient was taken to the operating room for a laparoscopic ileocaecectomy with complete resolution of symptoms. Preoperative localisation of the bleeding site may be difficult but is critically important in occult gastrointestinal bleeding. Procedure choice for a bleeding ileal diverticulum is dictated by the distance from the ileocaecal valve and the etiopathology of the bleed.

A comparison of the antegrade core trap and reverse bevel needles for EUS-guided fine-needle biopsy sampling of liver mass: a prospective randomized cross over study.

BACKGROUND: Data on the use of EUS-guided fine-needle biopsy (EUS-FNB) of solid liver mass (SLM) for pathology is limited. METHODS: To prove superiority of the diagnostic rate of the newly designed modified Menghini-type needle with a beveled side-slot near the needle tip with slot cutting edge directed 20-gauge antegrade bevel (group A) over the original 22-gauge reverse bevel (group B) for EUS-guided fine-needle biopsy (EUS-FNB) of solid liver mass (SLM) in a prospective crossover randomized controlled trial. RESULTS: The overall diagnostic accuracy rate of the 52 passes was 86.5% (45/52) and of group A versus B were 88.5% (23/26) versus 84.6% (22/26), respectively, p = 0.858. Tissue adequacy levels of both groups were not significantly different (grade A: B: C = 18:6:2 versus 16:7:3), p = 0.839). Grading of blood contamination of both groups was not significantly different. However, it was found that the group-A needles could biopsy tissue of significantly longer length than that of the group B; 1.3 cm (SD = 0.76) versus 0.8 cm (SD = 0.54); p = 0.007. CONCLUSION: The use of EUS-FNB of SLM is highly effective with similar levels of efficacy and number of adverse events between both types of needles. THE TRIAL REGISTRATION NUMBER: Thai Clinical Trial Registration No. TCTR2018081002.

Temporal trend in the natural history of ulcerative colitis in a country with a low incidence of ulcerative colitis from 2000 through 2018.

BACKGROUND/AIMS: The incidence of ulcerative colitis (UC) in Thailand (crude incidence rate of 0.28 per 100,000 persons) is much lower than in the West. The burden of UC varies in different populations. The aim of this study was to evaluate the natural history of UC over the two decades in Bangkok, Thailand. METHODS: This retrospective study included patients who were diagnosed with UC between 2000 and 2018 in 2 university hospitals. To evaluate changes in the disease course, we stratified patients into 2000-2009 cohort and 2010-2018 cohort. The cumulative probability of endoscopic healing, UC-related hospitalization and colectomy was estimated using the Kaplan-Meier method. RESULTS: A total of 291 UC patients were followed for total of 2,228 person-years. Comparison between 2 cohorts, there were no differences in disease pattern and severity whereas an increase in the combination use of oral and topical mesalamine and the early use of thiopurine was observed. Only 1% of patients for each cohort required biologic agent at 5 years. The rate of achieving mucosal healing increased from 15% to 46% at 3 years (P< 0.01). The rate of UC-related hospitalization decreased from 30% to 21% at 5 years (P< 0.05). The rate of colectomy decreased from 6% to 2% at 5 years (P< 0.05). CONCLUSIONS: The natural history of UC in a low incidence country was less aggressive than the West. Over the past two decades, the rates of UC-related hospitalization and colectomy have been decreasing which were similar to the West.

Validation of models using basic parameters to differentiate intestinal tuberculosis from Crohn's disease: A multicenter study from Asia.

BACKGROUND: Data on external validation of models developed to distinguish Crohn's disease (CD) from intestinal tuberculosis (ITB) are limited. This study aimed to validate and compare models using clinical, endoscopic, and/or pathology findings to differentiate CD from ITB. METHODS: Data from newly diagnosed ITB and CD patients were retrospectively collected from 5 centers located in Thailand or Hong Kong. The data was applied to Lee, et al., Makharia, et al., Jung, et al., and Limsrivilai, et al. model. RESULTS: Five hundred and thirty patients (383 CD, 147 ITB) with clinical and endoscopic data were included. The area under the receiver operating characteristic curve (AUROC) of Limsrivilai's clinical-endoscopy (CE) model was 0.853, which was comparable to the value of 0.862 in Jung's model (p = 0.52). Both models performed significantly better than Lee's endoscopy model (AUROC: 0.713, p<0.01). Pathology was available for review in 199 patients (116 CD, 83 ITB). When 3 modalities were combined, Limsrivilai's clinical-endoscopy-pathology (CEP) model performed significantly better (AUROC: 0.887) than Limsrivilai's CE model (AUROC: 0.824, p = 0.01), Jung's model (AUROC: 0.798, p = 0.005) and Makharia's model (AUROC: 0.637, p<0.01). In 83 ITB patients, the rate of misdiagnosis with CD when used the proposed cutoff values in each original study was 9.6% for Limsrivilai's CEP, 15.7% for Jung's, and 66.3% for Makharia's model. CONCLUSIONS: Scoring systems with more parameters and diagnostic modalities performed better; however, application to clinical practice is still limited owing to high rate of misdiagnosis of ITB as CD. Models integrating more modalities such as imaging and serological tests are needed.

Changes in inflammatory cytokines, antioxidants and liver stiffness after chelation therapy in individuals with chronic lead poisoning.

BACKGROUND: Chronic exposure to lead causes lead to accumulate mainly in the liver. In vivo studies have shown that lead toxicity is related to alterations in the inflammatory response. We aimed to evaluate the association between lead poisoning and liver fibrosis as well as the change in the degree of liver fibrosis, levels of inflammatory mediators and glutathione (GSH) after chelation therapy. METHODS: Workers from a battery factory who were exposed to lead for > 12 months and had a blood lead level (BLL) > 70 µg/dL were enrolled (n = 86) in the study. Participants underwent chelation therapy with intravenous CaNa2EDTA for 2 days followed by treatment with oral D-penicillamine for 90 days. The primary outcome was the change in the degree of liver fibrosis, which was presented as liver stiffness (LS) measured by FibroScan®. Secondary outcomes were the changes in the levels of serum GSH and inflammatory mediators such as tumor necrosis factor-alpha (TNF-α), interleukin-1ß (IL-1ß), and interleukin-6 (IL-6) after chelation therapy. RESULTS: Among the 86 participants, there was a positive correlation between the duration of lead exposure and LS (r = 0.249, p = 0.021). To avoid the confounding effect of obesity-related steatosis, only 70 individuals who had controlled attenuation parameters < 296 dB/m, BMI < 25 kg/m2 and normal waist circumference were included in the interventional analysis. After chelation, the mean LS significantly decreased from 5.4 ± 0.9 to 4.8 ± 1.4 kPa (p = 0.001). Similarly, all of the inflammatory cytokines studied significantly decreased after chelation (p < 0.001); TNF-α decreased from 371.6 ± 211.3 to 215.8 ± 142.7; the levels of IL-1ß decreased from 29.8 ± 1.7 to 25.9 ± 4.3; and the levels of IL-6 decreased from 46.8 ± 10.2 to 35.0 ± 11.9. On the other hand, the mean GSH level increased significantly from 3.3 ± 3.3 to 13.1 ± 3.7 (p < 0.001) after chelation therapy. CONCLUSION: The duration of lead exposure was significantly correlated with the degree of liver fibrosis. Chelation treatment was associated with increased levels of GSH and decreased levels of proinflammatory cytokines and could potentially reduce the degree of LS. TRIAL REGISTRATION: This study was retrospectively registered and approved by the Thai Clinical Trial Registry (TCTR) on 2019-11-07. The TCTR identification number is TCTR20191108001 .

Feasibility and safety of research sigmoid colon biopsy in a cohort of Thai men who have sex with men with acute HIV-1.

BACKGROUND: The gut-associated lymphoid tissue (GALT) is a major reservoir of HIV-1 established early in acute HIV-1 infection (AHI). Sampling tissue from GALT can provide information about viral reservoirs and immune responses but may be complicated during AHI for reasons such as high viral replication, CD4 T cell depletion and immune activation. Risk of adverse events (AEs) associated with research sigmoid colon biopsies was assessed in participants with AHI in Bangkok, Thailand. METHODS: Between 2009 and 2016, 170 biopsies collected from the sigmoid colon were performed during AHI and at follow-up visits (median 24 weeks post AHI diagnosis). Adverse event incidence was evaluated, as well as the associations of procedure timing, repetition and clinical parameters with AE risk. Negative binomial regression models were used to calculate incidence rate ratios and 95% confidence intervals. RESULTS: Among 103 participants (median age of 27 years, 97.1% male, 96.1% men who have sex with men), 87 sigmoidoscopies were completed during AHI and 83 at a follow-up visit. Approximately 30 biopsies were obtained per procedure for assessment of colonic viral load and HIV-1 reservoir, immunohistochemistry or phenotypic assays. All 11 AEs were grade 1 (6.5%) and included abdominal discomfort (n = 5, 2.9%), mild rectal bleeding (n = 5, 2.9%) and difficulty passing stool (n = 1, 0.6%). Biopsy-related AE risk was not significantly associated with age, HIV-1 RNA, CD4 T cell count, or number and time of biopsy. CONCLUSIONS: Complications of sigmoidoscopy with biopsy in participants with AHI were infrequent and mild. Longitudinal sampling of the sigmoid colon to evaluate the gut-associated HIV-1 reservoir can be safely performed as part of research studies.

Additional Candida albicans administration enhances the severity of dextran sulfate solution induced colitis mouse model through leaky gut-enhanced systemic inflammation and gut-dysbiosis but attenuated by Lactobacillus rhamnosus L34.

CANDIDA ALBICANS: is abundant in the human gut mycobiota but this species does not colonize the mouse gastrointestinal tract. C. albicans administration in dextran-sulfate solution (DSS) induced-colitis mouse model (DSS+Candida) might resemble more to human condition, therefore, a DSS colitis model with Candida administration was studied; first, to test the influence of fungi in DSS model and second, to test the efficacy of Lactobacillus rhamnosus L34. We demonstrated serum (1→3)-ß-D-glucan (BG) elevation in patients with IBD and endoscopic moderate colitis in clinical remission, supporting the possible influence of gut fungi toward IBD in human. Then, in mouse model, Candida gavage was found to worsen the DSS model indicated by higher mortality rate, more severe colon histology and enhanced gut-leakage (FITC-dextran assay, endotoxemia, serum BG and blood bacterial burdens) but did not affect weight loss and diarrhea. DSS+Candida induced higher pro-inflammatory cytokines both in blood and in intestinal tissue. Worsened systemic pro-inflammatory cytokine responses in DSS+Candida compared with DSS alone was possibly due to the more severe translocation of LPS, BG and bacteria (not fungemia) from gut into systemic circulation. Interestingly, bacteremia from Pseudomonas aeruginosa was more frequently isolated from DSS+Candida than DSS alone. In parallel, P. aeruginosa was also isolated from fecal culture in most of the mice in DSS+Candida group supported by prominent Gammaproteobacteria in fecal microbioata analysis. However, L. rhamnosus L34 attenuated both DSS+Candida and DSS model through the attenuation of gut local inflammation (cytokines and histology), gut-leakage severity, fecal dysbiosis (culture method and microbiome analysis) and systemic inflammation (serum cytokines). In conclusion, gut Candida in DSS model induced fecal bacterial dysbiosis and enhanced leaky-gut induced bacteremia. Probiotic treatment strategy aiming to reduce gut-fungi and fecal dysbiosis could attenuate disease severity. Investigation on gut fungi in patients with IBD is highly interesting.

Cytoprotective agent for peptic ulcer prevention in patients taking dual antiplatelet agents: A randomized, double-blind placebo-controlled trial.

BACKGROUND AND AIM: Long-term use of dual antiplatelets is increasing, and most patients need primary peptic ulcer prophylaxis. The long-term use of proton pump inhibitors (PPIs) is associated with adverse events. We evaluated the efficacy of rebamipide for peptic ulcer prevention. METHODS: This randomized controlled trial was conducted between July 2014 and November 2017. Patients receiving dual antiplatelets for ≥ 1 year with no history of peptic ulcer bleeding or perforation were recruited and randomly assigned to the rebamipide (300 mg/day) group or the placebo group. Patients who used proton pump inhibitors were excluded. The primary endpoint was a new mucosal break on esophagogastroduodenoscopy at 3 or 12 months after treatment initiation. The secondary endpoints were hematocrit changes from the baseline, gastrointestinal bleeding, and chest pain. Antiplatelet function was assessed. RESULTS: In total, 95 eligible patients were identified; 12 were excluded, and 83 patients were randomized, with 66 (79.5%) and 59 (71.1%) patients eligible at the 3- and 12-month follow ups, respectively. The baseline characteristics were equivalent between the groups. During the 12 months of follow up, 13 patients (43.3%) taking rebamipide and 19 (65.5%) taking the placebo experienced mucosal injury (P = 0.07). Two patients (6.7%) taking rebamipide and eight (27.6%) taking the placebo had peptic ulcers ≥ 5 mm or < 5 mm with pigmented spots (P = 0.03). The changes in hematocrit were not different between the two groups. Neither bleeding ulcers nor chest pain was observed. CONCLUSION: Rebamipide is safe and may prevent peptic ulcers ≥ 5 mm in diameter or those with pigmented spots in patients receiving dual antiplatelets for 1 year (NCT02166008).

Bimodal Chromoendoscopy with Confocal Laser Endomicroscopy for the Detection of Early Esophageal Squamous Cell Neoplasms.

BACKGROUND/AIMS: This study aimed to evaluate the diagnostic accuracy of dual-focus narrow-band imaging (dNBI) and Lugol'schromoendoscopy (LCE) combined with probe-based confocal laser endomicroscopy (pCLE) to screen for esophageal squamous cell neoplasms (ESCNs) in patients with a history of head and neck cancer. METHODS: From March to August 2016, dNBI was performed. Next, LCE was performed, followed by pCLE and biopsy. Histology has historically been the gold standard to diagnose ESCN. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of dNBI and LCE adjunct with pCLE were determined. RESULTS: Twenty-four patients were included. Ten ESCNs were found in 8 patients (33%). Forty percent of high-graded intraepithelial neoplasias and all low-grade intraepithelial neoplasias were overlooked by dNBI. The sensitivity, specificity, PPV, NPV, and accuracy of dNBI vs. LCE combined with pCLE were 50% vs. 80%, 62% vs. 67%, 36% vs. 44%, 75% vs. 91%, and 83% vs. 70%, respectively. CONCLUSION: The use of dNBI to detect ESCN was suboptimal. LCE with pCLE following dNBI had additional value for detecting esophageal dysplasia not detected by dNBI. The use of pCLE to detect dNBI-missed lesions yielded a high NPV, while pCLE-guided biopsy could reduce the number of unnecessary biopsies.

Transcatheter Examination of the Peritoneal Dialysis Catheter with the SpyGlass Direct Visualization System: A New Aid in Diagnosis and Salvation of Ultrafiltration Failure from Partial Catheter Obstruction.

Mechanical complications in peritoneal dialysis (PD), including intraluminal clogging of the PD catheter by fibrin, omentum, or blood clot, are major causes of outflow problems and, in rare cases, lead to technical failure. To visualize an intraluminal image of patients undergoing PD with ineffective ultrafiltration (UF), a SpyGlass fiber optic probe was inserted into the catheter, together with SpyBite biopsy forceps, should the removal of clogging materials be needed. Applying these transcatheter devices in 2 PD patients with unexplained UF failure led to the demonstration of omental plugging at the catheter tip in the first patient and demonstration of intraluminal blood clots in the second patient from whom clots were removal successfully. Both patients achieved better UF volume thereafter without procedure-related complications.

Liver Fluke-Associated Biliary Tract Cancer.

Cholangiocarcinoma (CCA) is an aggressive cancer arising from epithelial cells of the bile duct. Most patients with CCA have an unresectable tumor at the time of diagnosis. In Western countries, the risk of CCA increases in patients with primary sclerosing cholangitis, whereas liver fluke infection appears to be the major risk factor for CCA in Asian countries. A diagnosis of liver fluke infection often relies on stool samples, including microscopic examination, polymerase chain reaction-based assays, and fluke antigen detection. Tests of serum, saliva and urine samples are also potentially diagnostic. The presence of liver fluke along with exogenous carcinogens magnifies the risk of CCA in people living in endemic areas. The "liver fluke-cholangiocarcinoma" carcinogenesis pathways consist of mechanical damage to the bile duct epithelium, immunopathologic and cellular reactions to the liver fluke's antigens and excretory/secretory products, liver fluke-induced changes in the biliary tract microbiome and the effects of repeated treatment for liver fluke. A vaccine and novel biomarkers are needed for the primary and secondary prevention of CCA in endemic areas. Importantly, climate change exerts an effect on vector-borne parasitic diseases, and awareness of liver fluke should be enhanced in potentially migrated habitat areas.

The efficacy of Hemospray in patients with upper gastrointestinal bleeding from tumor.

BACKGROUND AND STUDY AIMS: Currently, conventional endoscopic treatments provide an unsatisfactory hemostatic outcome in upper gastrointestinal bleeding from tumor. Hemospray has been shown to be useful in many active gastrointestinal bleeding conditions. This study aimed to compare the efficacy of Hemospray and conventional endoscopic hemostasis. PATIENTS AND METHODS: Fourteen patients with active upper gastrointestinal bleeding from tumor were recruited. Hemospray was applied at the bleeding site until hemostasis was achieved. Four patients were excluded because they prematurely received definitive therapy to prevent further bleeding within 48 hours. Another 10 patients from historical control were matched based on the type of gastrointestinal tumors. The 14-day rebleeding rates, length of hospital stay (LOS) and mortality rate at 30-day follow up were assessed. RESULTS: Baseline characteristics including age, stage of tumor, and Blatchford score did not differ between the two groups. The 14-day rebleeding rate in the Hemospray group was 3 times lower than the control group but not statistically significant (10 % vs. 30 %; P = 0.60). LOS was no different between the 2 groups (28.2 ±â€Š21.2 vs. 23.8 ±â€Š12.5 days; P = 0.26). The 30-day mortality rate in the Hemospray group was 3 times lower than that of in the conventional therapy group but not significant (10 % vs. 30 %, P = 0.7). CONCLUSIONS: Hemospray is a promising therapy for initial hemostasis in upper gastrointestinal bleeding from tumor because it can achieve hemostasis during the first 14 days, thus potentially allowing sufficient time before appropriate definitive intervention is considered.

Efficacy of the Ovesco Clip for Closure of Endoscope Related Perforations.

Aim. To study the efficacy and other treatment outcomes of Ovesco clip closure of iatrogenic perforation. Methods. Retrospective study from 3 tertiary-care hospitals in Thailand. Patients with iatrogenic perforation who underwent immediate endoscopic closure by Ovesco clip were included. Patients' demographic data, perforation size, number of Ovesco clips used, fasting day, length of hospital stay, success rates, and complication rate were recorded. Technical success was defined as closure achievement during endoscopic procedure and clinical success was defined as the patient can be discharged without the need of additional surgical or radiological intervention. Results. There were 6 iatrogenic perforations in 2 male and 4 female patients. The median age was 59 years (range 39-78 years). The locations of perforation were 5 duodenal walls and 1 rectosigmoid junction. The median perforation size was 13 mm (range 10-40 mm). The technical success was 100% and the clinical success was 83.3%. The success rates per locations were 100% in colon and 80% in duodenum, respectively. The median fasting time was 5 days (range 1-10 days) and the median length of hospital stay was 10 days (range 2-22 days). There was no mortality in any. Conclusion. Ovesco clip seems to be an effective and safe tool for a closure of iatrogenic perforation.

Endoscopic ultrasound-guided needle-based confocal laser endomicroscopy for diagnosis of solid pancreatic lesions (ENES): a pilot study.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasound-guided needle-based confocal laser endomicroscopy (EUS-nCLE) has been shown to aid in the diagnosis of cystic pancreatic lesions. This is a pilot project to study its findings in patients with solid pancreatic lesions (SPLs) with a prospective single-blinded study design. METHODS: Patients with SPLs undergoing trans-gastric EUS fine needle aspiration (EUS-FNA) from July 2013 to March 2014 were prospectively enrolled. The nCLE diagnoses were compared with the final diagnoses. Researchers learned about the EUS-nCLE findings from previously published studies and applied it to diagnose SPLs. In the meantime, the findings were recorded. RESULTS: In total, 22 patients were recruited (mean age 62.7 years, SD 13.8 years; 14 men and eight women). The mean maximal tumor diameter was 36.0 mm (SD 10.9 mm). EUS-nCLE yielded satisfactory images in all patients during the first EUS procedure and diagnosed benign and malignant SPLs in 3 and 19 patients, respectively. Final diagnoses of malignant SPLs were made in 19 patients. Benign SPLs were eventually diagnosed in three patients, with confirmed the cytology and disease stability during the 12-month follow-up period. At the end of the project, based on the results of this current study, EUS-nCLE findings for malignant SPLs were dark clumping with or without dilated vessels (> 40 µm). There were two criteria for diagnosing benign lesions which were white fibrous bands and normal acini cells. The accuracy rate of EUS-nCLE was 90.9 % (20/22). One falsely diagnosed malignant SPL was an inflammatory mass from a recent acute pancreatitis. Another one with a pancreatic neuroendocrine tumor presenting with a symptomatic pseudocyst was incorrectly diagnosed as an inflammatory mass. This was likely from sampling error of the EUS-nCLE probe in an inflammatory area. Only one patient had post EUS-FNA bleeding but did not require a blood transfusion. The inter-observer agreement among three blinded endoscopists was almost perfect (Kappa 0.82). CONCLUSION: EUS-nCLE is a promising technique for the diagnosis of SPLs with good inter-observer agreement. Study registration : TCTR20140402001.

Value of probe-based confocal laser endomicroscopy (pCLE) and dual focus narrow-band imaging (dNBI) in diagnosing early squamous cell neoplasms in esophageal Lugol's voiding lesions.

BACKGROUND AND STUDY AIMS: Lugol's chromoendoscopy provides excellent sensitivity for the detection of early esophageal squamous cell neoplasms (ESCN), but its specificity is suboptimal. An endoscopy technique for real-time histology is required to decrease the number of unnecessary biopsies. This study aimed to compare the ESCN diagnostic capability of probed-based confocal laser endomicroscopy (pCLE) and dual focus narrow-band imaging (dNBI) in Lugol's voiding lesions. PATIENTS AND METHODS: Patients with a history of head and neck cancer without dysphagia were recruited. Lugol's voiding lesions larger than 5 mm were sequentially characterized by dNBI and pCLE by two independent operators. Finally, all lesions larger than 5 mm were biopsied followed by histological analysis, which is considered to be the gold standard in cancer diagnosis. The primary outcomes were the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the accuracy of the two techniques. RESULTS: In total, 44 patients were enrolled with a mean age of 60 years; 80 % were male. Twenty-one Lugol's voiding lesions larger than 5 mm were detected in 12 patients. Seven lesions (33 %) from four patients were histologically diagnosed as ESCNs (four with high grade dysplasia and three with low grade dysplasia). The other 14 lesions were histologically confirmed as non-neoplastic: active esophagitis, glycogenation with inflammation, acute ulcer, inlet patch, and unremarkable changes. The sensitivity, specificity, PPV, NPV, and accuracy of pCLE vs. dNBI were 83 % vs. 85 %, 92 % vs. 62 %, 83 % vs. 54 %, 92 % vs. 89 %, and 89 % vs. 70 %, respectively (NS). CONCLUSIONS: Asymptomatic patients with a history of head and neck cancer underwent Lugol's chromoendoscopy based ESCN surveillance. Further characterization of the Lugol's voiding lesions by advanced imaging showed that both pCLE and dNBI provided good sensitivity in diagnosing ESCN, and pCLE tended to provide higher specificity, PPV, and accuracy than dNBI. Perhaps the trend of lower specificity of dNBI in this study was possibly because of the interference from Lugol's stain on the interpretation of intrapapillary capillary loops (IPCLs). Further study is required to seek a significant difference in the performance of dNBI and pCLE in a larger group of patients.

Aloe vera attenuated gastric injury on indomethacin-induced gastropathy in rats.

AIM: To evaluate the protective effects of Aloe vera on gastric injury in rats with indomethacin (IMN)-induced gastropathy. METHODS: Male Sprague-Dawley rats were randomly divided into three groups. Group 1 (control, n = 6) was given distilled water (DW) orally. Group 2 (IMN, n = 6) was given oral IMN (150 mg/kg) dissolved in 5% sodium bicarbonate (NaHCO3 (-)) at time 0 and 4 h. Group 3 (Aloe vera-treated, n = 6) was given oral Aloe vera (150 mg/kg) dissolved in DW and IMN at time 0 and 4 h. Eight hours later, the stomach was removed to determine gastric malondialdehyde (MDA), the number of interleukin (IL)-18 positive stained cells (%) by immunohistochemistry, and for histopathological examination. Then, the serum was collected to determine tumor necrosis factor (TNF)-α and cytokine-induced neutrophil chemoattractant (CINC)-1 by sandwich enzyme linked immunosorbent assay method. RESULTS: In the IMN group, serum TNF-α, CINC-1 and gastric MDA were significantly increased when compared to the control group (27.78 ± 1.52 pg/mL vs 85.07 ± 49.11 pg/mL, P = 0.009; 104.55 ± 45.80 pg/mL vs 1054.70 ± 20.38 pg/mL, and 1.74 ± 0.21 nmol/mg vs 9.36 ± 1.07 nmol/mg protein, P = 0.000, respectively). The mean level of TNF-α, CINC-1 and gastric MDA in the Aloe vera-treated group were improved as compared with the IMN group (85.07 ± 49.11 pg/mL vs 35.19 ± 1.61 pg/mL, P = 0.021; 1054.70 ± 20.38 pg/mL vs 813.56 ± 239.04 pg/mL, P = 0.025; and 9.36 ± 1.07 nmol/mg vs 2.67 ± 0.64 nmol/mg protein, P = 0.000, respectively). The number of IL-18 positive stained cells (%) in the gastric epithelial cells of the IMN group was significantly higher than the control group (5.01% ± 3.73% vs 30.67% ± 2.03%, P = 0.000, respectively). In contrast, Aloe vera treatment decreased the number of IL-18 positive stained cells (%) significantly when compared with the IMN group (30.67% ± 2.03% vs 13.21% ± 1.10%, P = 0.000, respectively). Most rats in the IMN group developed moderate to severe gastric inflammation and erosions. The gastric erosions and neutrophil infiltration scores were significantly reduced in the Aloe vera-treated group. CONCLUSION: Aloe vera attenuated IMN-induced gastropathy in rats by the reduction of oxidative stress, inflammation, and improvement of gastric histopathology.