Blue Rubber Bleb Nevus Syndrome because of 12 Years of Iron Deficiency Anemia in a Patient by Double Balloon Enteroscopy; A Case Report and Review of Literature.

Blue rubber bleb nevus syndrome (BRBNS) is a rare disorder comprised of venous malformation mostly involving the skin and gastrointestinal (GI) tract but can also involve other visceral organs. The most predominant site of GI tract involvement is the small bowel. In patients with GI lesions, treatment depends on the severity of bleeding, and extent of involvement. Conservative therapy with iron supplementation and blood transfusion is appropriate in cases with mild bleeding but in severe cases endoscopic and surgical interventions would be beneficial. Also, medical therapy with sirolimus significantly reduces bleeding. A 20-year-old woman was referred to our hospital after transfusion of six units of packed cell because of several episodes of lower GI bleeding within the past three months in the form of melena and a single episode of hematochezia. Her last hemoglobin level before admission was 10mg/dl. She underwent various unsuccessful investigations since she was eight years old to find the origin of refractory iron deficiency anemia. In upper endoscopy, five bleeding polypoid lesions were discovered in the jejunum. Lesions were excised by snare polypectomy. Over a six-month follow-up period, no signs of lower GI bleeding were noted and the patient had a normal hemoglobin level.

Pulmonary Complications in Candidates for Liver Transplantation.

The liver plays a pivotal role in maintaining the homeostasis of various organ systems. Also, end-stage liver disease and its complications are major causes of morbidity and mortality among adults. Individuals who develop a chronic liver disease are at increased risk of progression to multi-organ dysfunction, including the pulmonary system. The clinical complications of pulmonary problems related to the presence of liver disease range from mild (such as hypoxemia) to life-threatening diseases (such as portopulmonary hypertension and hepatopulmonary syndrome). Herein, the major pulmonary complications related to liver cirrhosis and considerations for performing liver transplantation are reviewed.

Recurrence of fatty liver disease following liver transplantation for NAFLD-related cirrhosis: Current status and challenges.

Non-alcoholic fatty liver disease (NAFLD) is emerging as a major health problem worldwide. NAFLD is a continuum of disease ranging from mild liver steatosis to severe steatohepatitis, which will ultimately lead to end-stage liver disease with high morbidity and mortality rates. This disorder is considered as a silent liver disease. The metabolic syndrome and its components are accounted as the major risk factors for the progression of NAFLD to NASH and cirrhosis. Liver transplantation is considered as an appropriate treatment for the end-stage disease. For the last two decades, NASH has been the most common reason for liver transplantation, especially in the developed countries; however, the outcome of post-transplantation in these patients is of a great concern. The recurrent NASH and NAFLD seem to be the usual issues in LT. Steatosis appears in more than 80% of LTs; however, re-transplantation caused by steatohepatitis is rare. Recently, several risk factors of the recurrent NAFLD, including age, donor steatosis, metabolic syndrome, and immunosuppressant agents, have been introduced. Among the metabolic syndrome components, obesity seriously has negative effects on the outcomes of post-liver transplantation in patients. Unfortunately, there is no standard medicine to prevent or treat the recurrent NAFLD; however, it seems that weight loss and lifestyle modification play critical roles in controlling or inhibiting the recurrent NAFLD or NASH.

Successful Removal of a Biliary Stent in the Jejunum Using Double-Balloon Enteroscopy.

BACKGROUND: Plastic biliary stent placement has been widely used as a safe approach for the management of hilar neoplasms or the dilation of benign biliary obstruction. Despite the complexity of this procedure, this approach is followed by a few complications. The incidence rate of stent migration is about 10%. In a majority of cases, the migrated stents are retained within the gastrointestinal tract and pass through the intestine with no complication or need for medical intervention. CASE REPORT: In this paper, we described the case of the migrated biliary stent with prolonged abdominal pain, which was removed successfully by using double-balloon. CONCLUSION: In the case of patient with prolonged abdominal pain and previous history of biliary stent placement, migration of stent should be considered as differential diagnosis and Double-Balloon Enteroscopy can be a safe approach in those cases.

The association between serum 25OHD levels and hypothyroid Hashimoto's thyroiditis.

BACKGROUND: Vitamin D is shown to be a potent immunomodulator. Considering the potential role of low serum vitamin D levels in autoimmune disorder, we evaluated the association between Hashimoto's thyroiditis (HT) (with subclinical or overt hypothyroidism) and serum 25-hydroxyvitamin D (25OHD) levels in an Iranian population. METHODS: A total number of 86 individuals were enrolled. The case group included 41 patients with hypothyroid HT (overt or subclinical). The control group comprised 45 healthy euthyroid persons. Serum 25OHD levels were measured in all subjects. THE CASE: control ratio of geometric means of 25OHD levels was 0.66 (95 % CI: 0.49-0.90; P = 0.008). There was a significant inverse association between serum 25OHD levels and HT (OR: 0.81 for 5 ng/ml increase in 25OHD level, 95 % CI: 0.68-0.96; P = 0.018). This association remained significant after adjustment for potential confounding factors including age, sex and BMI. CONCLUSIONS: Our study suggested that higher serum 25OHD levels was associated with decreased risk of HT so that each 5 ng/ml increase in the serum 25OHD levels results in 19 % decrease in odds of HT.

Effect of general anesthesia during GI endoscopic procedures on patient satisfaction.

AIM: To compare the conventional GI endoscopy and using general anesthesia during the procedure regarding the satisfaction and acceptance among Iranian patients. BACKGROUND: Ability to measure and assess the patients' satisfaction with colonoscopy and upper endoscopy will improve the quality of health care provided by gastroenterologists and thus resulting in better acceptability of endoscopy. PATIENTS AND METHODS: In a prospective, multicenter, non-randomized clinical trial 756 patients were included between 2009 and 2010. A satisfaction developed questionnaire was answered by the patients who were candidate for elective upper and/or lower GI endoscopy within 72 hours after the procedure. Total satisfaction score was measured and compared between endoscopy patients with and without anesthesia. Different variables analyzed in order to find the influencing factors in patient satisfaction during the endoscopic procedures. RESULTS: The mean age of patients was 40.7 ± 15.1 years and 59% of them were female. Overall, 50.5% of patients underwent general anesthesia during the endoscopic procedure. There was a significant correlation between education level and satisfaction with the endoscopy. Also, anesthesia during endoscopy significantly increased the total satisfaction score of the patients (OR= 2.07, 95% CI: 1.24-2.9, P < 0.0001). CONCLUSION: The level of patient's education and using anesthesia during GI endoscopy were two factors influencing the total patient satisfaction with the endoscopic procedures. Thus, we suggest using anesthesia for GI endoscopic procedures.

Evaluation of patients' satisfaction with anesthesia in gastrointestinal endoscopic procedures in Iran.

AIM: The purpose of this study was to assess satisfaction level and related factors among patients who had an anesthesia during endoscopic procedures; and also validate a questionnaire for evaluating satisfaction with anesthesia. BACKGROUND: The level of patient satisfaction with GI endoscopic procedure is an important criterion to indicate the level of expertise in endoscopy. PATIENTS AND METHODS: We performed a prospective descriptive study at Resalat Hospital, Tehran, Iran. Three hundred seventy nine elective patients undergoing anesthesia for GI endoscopy procedure in 2010 were recruited. A 20-item questionnaire was used to evaluate the satisfaction with the anesthesia. The questionnaire was answered within 72 hours after the procedure. The satisfaction was graded into four major groups: anesthesia delivery, procedural recall, side effects and global satisfaction. RESULTS: The level of satisfaction with anesthesia and its related factors were determined. The mean score of satisfaction with anesthesia delivery, procedural recall, side effects, global satisfaction, and total satisfaction (question 1-16) were 6.15 ± 1.23, 5.65± 1.48, 5.24± 1.16, 5.01± 1.29, and 5.46± 1.14, respectively. There was a significant difference in patients' satisfaction level between different jobs (p=0.02) as well as different levels of education (p=0.01). CONCLUSION: Higher educational level was accompanied with greater satisfaction. The highest satisfaction score was seen among retired patients and the lowest level was found in housekeepers.