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Background Neuroendocrine tumors (NETs), as a rare and heterogeneous category of solid tumors, feature various morphologies and behaviors. In recent years, the incidence of NETs has continued to increase. Endoscopic mucosal resection (EMR) is one of the therapeutic modalities for the treatment of gastric and rectal NETs. Methods We evaluated patients with well-differentiated NETs of the stomach, duodenum, or rectum between 2011 and 2018. In this study, all cases with tumors confined to the mucosal or submucosal layers and smaller than 20 mm were resected using the EMR technique. We used EUS, CT scan, or MRI to exclude patients with advanced disease. All patients were actively monitored for recurrence according to the recommended protocols. Results A total of 36 patients with NETs entered the study; 17 (47.2%) were female and the remaining 19 (52.8%) were male, with a total age range of 20–74 years (mean: 52.47 ± 13.47 years). Among the tumors, 31 cases (86.1%) were G1 and the remaining 5 (13.9%) were G2. Based on the pathology reports, 22 tumors (61.1%) were smaller than 1 cm, while the remaining 14 (38.9%) were between 1–2 cm. Twenty-two patients (61.1%) had a margin of specimen involved with the tumor. No recurrence was observed during the mean follow-up time of 63.5 ± 19.8 months (range: 39–103 months). All 36 cases survived during the study period. Conclusion Conventional EMR procedure provides low chance of R0 (complete resection) achievement in gastrointestinal NETs smaller than 20 mm and limited to the mucosa or sub mucosa. However, it could be an option if patients are closely followed. Postoperative marginal involvement is not a reliable predictor of disease recurrence, which may be explained by the deleterious effect of heat coagulation and cauterization applied during tumor removal.

BACKGROUND Metabolic syndrome can be considered as a combination of metabolic disorders that may led to an increased risk of some diseases such type II diabetes, cardiovascular diseases, myocardial infarction, and is the cause of mortality from coronary artery disease. Its prevalence is particularly high in women. There is evidence that pancreatic fat, as a key factor in non-alcoholic fatty liver and metabolic syndrome, numerates as an early indicator of abnormal fat deposition. METHODS In this study, we enrolled 262 patients, who were admitted to Ali Ibn Abi Talib Hospital in Rafsanjan city, using the non-random-sequential method. Data collection tools were a questionnaire containing demographic characteristics (age, sex, history of diseases, etc.) and a checklist including MetS (based on NCEP/ATP III criteria and Diabetes Committee), pancreatic density (P), and spleen (S) and pancreatic index (P/S). One-way ANOVA and Post-Hoc and Chi-square tests were used for statically analyses. RESULTS The prevalence of metabolic syndrome was 34.8%, index of pancreas in the group without and with metabolic syndrome were 0.85 ± 0.11 and 0.74 ± 0.29 Hounsfield Units, respectively. CONCLUSION Compared with the group with at least one criterion and the group with the complete criteria (p = 0.013), pancreas index was higher in the group without metabolic syndrome.

In patients with severe biliary pancreatitis, delayed cholecystectomy associated with a high risk of recurrence is recommended. The current study aimed to evaluate the effect of common bile duct (CBD) stenting on reducing gallstones migration and recurrence of symptoms in patients with pancreatitis and delayed cholecystectomy candidates. To this purpose, the randomized, controlled clinical trial was performed on 40 patients with biliary pancreatitis who were candidates for delayed cholecystectomy. Patients were randomly divided into two groups of A and B that underwent CBD stenting after ERCP and received endoscopic treatment without stenting, respectively. A checklist recorded demographics and complications. Group A was followed up after four weeks to remove the stent and record the complications. Group B underwent MRCP to examine the migration of new gallstones as well as the complications. Of the 40 patients, 20 subjects (11 males and 9 females) were allocated to each group, matched for demographic variables. In the one-month follow-up, only one subject in group A manifested symptoms of gallstone migration and recurrence, while in group B, recurrence was observed in 6 patients (P = 0.037). There was no significant difference in the success rate of ERCP and the incidence of complications between the two groups. CBD stenting in patients with biliary pancreatitis and gallstone could reduce the risk of recurrence and remigration of gallstones in delayed cholecystectomy cases.

Gastric cancer (GC) is still ranked fourth among malignant cancers and remained as the second leading cause of cancer related death. There is mounting evidence that emphasizes on the need for further investigation on the specific receptors overexpression roles in GC progression. Low efficiency and impotence of the common methods for targeting gastric tumorigenesis and related metastases are enough to convince researchers to continue their investigation on new approaches of effective GC targeting. Due to the suitable characteristics of peptides, such as high affinity and specificity, they have great potential for cancer cell targeting. Overexpression of specific targets in GC can facilitate the application of peptide-based pharmaceuticals for effective tumor targeting and therapy and early diagnosis with help of fluorescents or radionuclides. In this review article, we paid particular attention to the characterization of peptide-based pharmaceuticals and radiopharmaceuticals that have been investigated in recent years for GC diagnosis and therapy.

Background: After the spread of novel coronavirus disease 2019 (COVID-19) from Wuhan to Iran, gastroenterology clinics, was faced with a large number of patients who were suspected of being infected with the SARS-CoV-2. Among refereed patient, the incidence of pure hyperbilirubinemia as rare gastrointestinal (GI) symptoms was obvious. Methods: : In this case series, we have reported the clinical data in details for patients with COVID-19 who have been admitted to the Shahid Beheshti Hospital in Qom city, from 3 March to 3 August 2020. COVID infection, be confirmed by using real-time reverse-transcriptase polymerase chain reaction (rRT-PCR) and chest computed tomography (CT) scan, as well. Results: According to the clinical findings, pure hyperbilirubinemia may consider as rare gastrointestinal (GI) symptom of COVID-19. However, it is possible that the other GI enzymes values fall in to the normal range. Conclusion: In some infected patients, GI physicians may face hepatic involvement as pure hyperbilirubinemia. At the age of COVID-19 crisis, all GI physicians should be aware of the possible occurrence of hepatic involvement as an important prognosis of COVID pneumonia and it should be exactly addressed in new referred patients to GI clinic.

The factors affecting the dynamics of lengthening of symptoms and serologic responses are not well known. In order to see how the serologic responses change in relation to the clinical features, we selected a group of 472 adults with a positive IgM/IgG antibody test result from a baseline study of the anti-SARS-CoV-2 seropositivity, assessed their COVID-19 and past medical histories, and followed them up in about 3 months. Nearly one-fourth of the subjects were asymptomatic at the baseline; 12.8% subjects became symptomatic at the follow-up (FU) when 39.8% of the subjects had some persisting symptoms. At the baseline, 6.1% showed anti-SARS-CoV-2 IgM positive, 59.3% only for IgG, and 34.5% for both. At the FU, these figures declined to 0.6, 54.0, and 4.4%, respectively, with the mean IgM and IgG levels declining about 6.3 and 2.5 folds. Blood group A was consistently linked to both sustaining and flipping of the gastrointestinal (GI) and respiratory symptoms. The baseline IgM level was associated with GI symptoms and pre-existing cirrhosis in multivariate models. Both of the baseline and FU IgG levels were strongly associated with age, male, and lung involvement seen in chest computed tomography (CT)-scan. Finally, as compared with antibody decayers, IgM sustainers were found to be more anosmic [mean difference (MD): 11.5%; P = 0.047] with lower body mass index (BMI) (MD: 1.30 kg/m2; P = 0.002), while IgG sustainers were more commonly females (MD: 19.2%; P = 0.042) with shorter diarrhea duration in the FU (MD: 2.8 days; P = 0.027). Our findings indicate how the anti-SARS-CoV-2 serologic response and COVID-19 clinical presentations change in relation to each other and basic characteristics.

BACKGROUND Gastrointestinal endoscopic procedures are widely used for diagnostic and therapeutic measures. Analgesia and sedation/anesthesia are inseparable parts of these studies and their related complications are inevitable. METHODS In a retrograde descriptive study in Shahid Beheshti Hospital, affiliated to Qom University of Medical Sciences, Qom, Iran from March 2013 to March 2017, we gathered information regarding common anesthesia related complications and analyzed them. RESULTS 44659 procedures were performed during the study period and records of 21342 men (47.79%) and 23317 women (52.21%) were evaluated. Hemodynamic instability (9998; 22.39%), dysrhythmia (1600; 3.58%), desaturation (608; 1.36%), prolonged apnea (34; 0.08%), aspiration (43; 0.10%), postoperative nausea and vomiting (PONV) (636; 1.42%), headache (106; 0.24%), delirium (51; 0.11%), aphasia (1; 0.00%), masseter muscle spasm (1; 0.01%), myocardial infarction (2; 0.00%), and death (5; 0.01%) were seen in the patients. CONCLUSION Sedation/anesthesia is enough safe in gastrointestinal endoscopic procedures to enhance the patients’ satisfaction and cooperation. If anesthesia with spontaneous breathing and unsecure airway is selected for this purpose, vigilance of anesthesia provider will be the key element of uneventful and safe procedure.

Background and Objectives: Ulcerative colitis (UC) is a type of inflammatory bowel disease (IBD), which is identified by inflammation and damage to colonic mucosal cells and leads to ulceration and bleeding. This study aims to investigate the relation of demographic and clinical variables with the severity of the disease in patients with UC relapse. Methods: This cross sectional study was conducted on 65 patients with UC relapse referred to Shahid Beheshti hospital during 2017-2018. Demographic, clinical, and laboratory data were collected using a checklist. Data were analyzed by statistical tests of ANOVA and Chi-square. Results: In this study, among 65 participants, 35 were male and 30 were female. The mean age of the patient was 36±14 years, of whom, 40% had mild and 60% moderate and severe relapse of the disease. From all studied variables, young age (p=0.050), higher body temperature (p=0.019), higher pulse rate, lower level of hemoglobin, and higher levels of ESR and WBC (all with p

Background: Numerous studies have evaluated the impact of Helicobacter pylori (H. pylori) eradication on the number, severity, and recurrence of migraine attacks. But the association of migraine, H. pylori, and gastrointestinal (GI) presentation is challenging. The aim of the current study was to investigate the correlation between migraine, H. pylori, and peptic ulcers among patients with dyspepsia undergoing upper GI endoscopy. Methods: 305 patients with dyspepsia referring to our endoscopy ward, Shahid Beheshti Hospital affiliated to Qom University of Medical Sciences, Qom, Iran, for upper GI endoscopy filled out the study questionnaire. If a patient was experiencing headaches and the migraine was confirmed by neurologists, he/she was asked to answer the questions related to migraine, which were prepared exactly from Migraine Disability Assessment (MIDAS) questionnaire. The relation between migraine and confirmed H. pylori contamination was investigated using statistical models. Results: Of all the 305 patients, 133 (43.6%) had confirmed episodic migraine headaches (MHs) and 177 patients (58.04%) had positive RUT for confirming H. pylori contamination, of which 123 (69.5%) had confirmed migraine. 52 (17.0%) had duodenal peptic ulcer(s), of which, 49 (94.2%) had a positive rapid urease test (RUT) (P < 0.001). 20 (6.5%) of all patients had the gastric peptic ulcer(s) which did not have a significant relation with H. pylori contamination. There was a significant relationship between the peptic ulcer site and migraine. In total, 177 patients (58.0%) had a positive RUT. History of migraine was significantly positive in those with positive H. Pylori contamination. Notably, multivariable analysis demonstrated a significant relation of H. pylori and migraine at younger ages. Conclusion: The prevalence of H. pylori and migraine in patients with dyspepsia seems to be high. Moreover, there is a meaningful association between migraine, duodenal peptic ulcers, and H. pylori infection, too.

Background: Some disease-specific Helicobacter pylori virulence genes can be used for predicting the outcome of diseases. Thus, the current study aimed to explore the frequency of the vacA, cagA, sabA, dupA, babA, oipA, and iceA1 genes in H. pylori isolates, and to determine whether any association exists between the expression of these genes and gastric cancer (GC).Methods: H. pylori isolates were collected from individuals with digestive diseases. The cagA, vacA, dupA, sabA, babA, oipA, and iceA1 genes were determined by PCR. The qRT-PCR was used for expression analysis of the tested genes. Results: The presence of the cagA, vacA, dupA, sabA, babA, oipA and iceA1 genes in H. pylori isolates were 41.3%, 95.5%, 31.0%, 93.1%, 55.1%, 82.7%, and 62.0%, respectively. The cagA, dupA, and babA expression in the GC patients was statistically higher than that of the control group (P H. pylori virulence genes among individuals with gastric diseases in the Iranian population. The cagA, dupA, and babA expression were significantly higher in the GC patients, thus, it may suggest that screening of these genes may help identify peoples at higher risk for GC.

Endoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure that is widely used for diagnosis and treatment of biliary and pancreatic diseases. With respect to its growing application, the present study aims to evaluate ERCP outcomes and complications. This cross-sectional study was performed using the data from 824 patients who underwent ERCP during 2014-2017 in Qom Shahid Beheshti hospital. Data were collected by a checklist and analyzed using SPSS V22. Among 824 patients, 397 (48.18%) were male and 427 (51.82%) were female with a mean age of 47 ± 6 years. The most common indications for ERCP were choledocholithiasis (78.28%) and cholestasis (20.27%), respectively. Total prevalence of complications was 15.66% and mortality rate was 0.72%. The most common complications were pancreatitis (9.59%) and bleeding (3.28%), respectively. A serum amylase level of greater than 160 could predict pancreatitis with sensitivity of 93.3% and specificity of 90.3%. Endoscopic retrograde cholangiopancreatography-related complications are inevitable but can be controlled by early diagnosis and clinical experience. Severe complications and high-risk patients may increase the mortality of the procedure.

Background The role of common bile duct (CBD) stenting in the establishment of bile stream in the elderly patients and the ones who are not good candidates for surgery due to not responding to treatments was well documented in previous studies. The current study aimed at investigating the effect of adding Ursodeoxycholic acid (UDCA) to CBD stenting alone in order to reduce the size of large and multiple CBD stones. Methods Clinical outcomes including success rates in CBD stones clearance, incidence of pancreatitis, perforation, bleeding, as well as, decrease in size of stones and liver enzymes after a two-month period were assessed in the UDCA + CBD stenting group. Results A total of 64 patients referring to Shahid Beheshti Hospital in Qom, Iran with multiple or large CBD stones (above three or larger than 15 mm) received standard endoscopic therapies and UDCA + CBD stenting (group B) and controls only received standard endoscopic therapies with only CBD stenting (group A). The mean reduction in the size of stones in group B was significantly higher than that of group A (3.22 ± 1.31 vs 4.09 ± 1.87 mm) (p = 0.034). There was no difference in the incidence rate of complications including pancreatitis, cholangitis, bleeding, and perforation between the two groups (P > 0.05). Conclusion Adding UDCA to CBD stenting, due to decrease in the stone size and subsequently facilitation of the stones outlet, can be considered as the first-line treatment for patients with large and multiple CBD stones. Also, in the cases with large or multi stones may be effective in reducing size and subsequently stone retrieval. Trial registry The study protocol was approved by the Ethics Committee of Qom University of Medical Sciences (ethical code: IR.MUQ.REC.1397.075); the study was also registered in the Iranian Registry of Clinical Trials (No. IRCT20161205031252N8). This study adheres to CONSORT guidelines.

BACKGROUND: Several treatment strategies are available to treat achalasia. Although combined therapy has been used for several years, there are limited data on long-term outcomes. We aimed to determine its long-term efficacy in patients who were resistant or those with rapid relapse. METHODS: In this prospective study, we reviewed the records of 1100 patients with achalasia, who were candidates for pneumatic balloon dilatation (PBD) in our center from 1996 to 2018. We enrolled 197 patients resistant to initial treatment or with rapid relapse of symptoms after three sessions of PBD. Clinical evaluation and time barium esophagogram (TBE) were done before treatment, a month afterward, and when clinical symptoms increased in order to confirm relapse, and at the end of follow-up. RESULTS: A total of 168 patients accepted combined therapy. The mean duration of follow-up was 9.04 years. Achalasia symptom score (ASS) dropped from 10.82 to 3.62 a month after treatment and was 3.09 at the end of the follow-up ( p =0.0001 and 0.001). TBE had a decrease in mean height of barium one month after treatment (9.23 vs. 5.10, p =0.001), and this reduction persisted until the end of follow-up (3.39, p = 0.001). Vantrappen score at the end of the follow-up showed 56 patients in excellent, 51 in good, 33 in moderate, and 14 in poor condition (89% acceptable response rate). CONCLUSION: Our results showed the long-term efficacy of combined treatment in patients with achalasia who otherwise had to undergo a high-risk and costly procedure, which makes it a safe and effective alternative for myotomy.

Introduction: Considering the increasing number of patients referred to gastroenterology clinics, we report a suspected case of coronavirus disease 2019 (COVID-19) with only gastrointestinal (GI) presentation in Qom, Iran. Case Presentation: A 74-year-old man with epigastric pain, diarrhea and vomiting for one week was treated, based on the routine abdominal treatment protocol. Since all GI symptoms were resistant to therapy, we decided to perform laboratory assays for a more accurate diagnosis of the disease. Considering the persistence of abdominal pain and nausea, abdominal and pelvic computed tomography (CT) scans, as well as endoscopy and colonoscopy, were performed. After performing the chest CT scan, we noticed the involvement of the lungs. The patient did not have any respiratory symptoms, and at the time of his hospitalization, the COVID-19 epidemic had been reported in Iran. With the progression of the disease, he started to experience mild fever (38°C). Using a specific COVID-19 kit, he was diagnosed with COVID-19 after precise evaluations. However, without any medications, all of his symptoms subsided after 2 - 3 weeks. Conclusions: It is important for all physicians to know that some pure GI symptoms, which are resistant to therapy, may be the only symptoms in suspected COVID-19 patients. Timely diagnosis and isolation of these patients can guarantee population to avoid the spread of this highly contagious infection.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is an uncommon systemic allergic reaction, which usually occurs due to a specific medication. The most common presentation is fever, skin eruption, and lymphadenopathy that presents two to eight weeks after exposure to the culprit drug. In some cases, evidence of internal organ involvement including renal failure, respiratory symptoms, or liver involvement may present. These symptoms may present weeks to months after the exposure or even discontinuing the drug, which makes the diagnosis challenging. This report presents a young man with first presentation of icter and elevated liver enzymes, whose laboratory and imaging studies failed to diagnose the disease. A liver biopsy was performed and the pathologist reported hepatocellular carcinoma (HCC). A high level of serum alpha-fetoprotein was consistent with the histologic findings, but concerning the uncommon clinical setting, the pathologic specimen was reviewed by another pathologist, which reported hepatocyte regeneration following hepatitis. This finding was consistent with elevated serum alpha-fetoprotein. A retrospective review revealed the history of using ceftriaxone nine months before the presentation and his final diagnosis was the DRESS syndrome with a dramatic response to corticosteroid treatment.

Cystic echinococcosis disease is a parasitic and zoonotic disease which is caused by Echinococcosis granulosus, which is endemic in Mediterranean Region and Middle East countries, including Iran. Cyst formation usually occurs in the liver and grows slowly in a spherical shape. The patients are usually asymptomatic until the lesion reaches a significant size or becomes complicated by rupture. Hepatic lesions are usually single. Diagnosis could be made on the basis of imaging studies including computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound study, especially for liver involvement. Serologic studies are usually helpful and antibody detection is more sensitive than antigen. This article introduces a middle aged man who was presented to the emergency department with acute pleuritic chest pain. Further evaluations revealed coexisting liver and chest hydatid cyst with rupture of the liver cyst in to the pleural cavity, following rupture of the diaphragm. Then diagnosis and treatment are discussed.

Background: As the COVID-19 pandemic unfolded, rapid case increase was observed in multiple cities in Iran. However, in the absence of seroprevalence surveys, the true infection rate remains unknown. In this population-based study we assessed the seroprevalence of SARS-CoV-2 antibodies in eighteen cities of Iran. Methods: We randomly selected and invited study participants from the general population (N = 3,547) and occupations with high risk of COVID-19 exposure, defined as high-risk population (e.g., supermarket employees) (N = 5,391), in eighteen cities of Iran. SARS-CoV-2 ELISA kits were used to detect antibody against COVID-19. Crude, population weight adjusted, and test performance adjusted seroprevalence rates were estimated. Findings: The population weight adjusted and test performance adjusted prevalence rates of antibody seropositivity in general population were 13·1% (95% CI 11·6-14·8%) and 18·5% (95% CI 16·1-21·3%), respectively. The population-weighted seroprevalence estimate implies that 3,290,633 (95% CI 2,907185-3,709,167) individuals, from the eighteen included cities in this study, were infected by end of April 2020.The overall prevalence rate was higher among individuals aged ≥ 60 years (32·0%, 95% CI 23·9-40·8%) and with comorbidity condition (23·7%, 95% CI 18·5-28·8%). The estimated seroprevalence of SARS-CoV-2 antibodies varied greatly by city and the highest population test-adjusted prevalence rates were in Rasht 78·1% (95% CI 58·3-98·3%) and Qom (66·5%, 95% CI 39·9-95·4%) cities. The test-adjusted prevalence did not differ between low and high-risk populations and was about 20.0%. Interpretations: The findings of this study imply that prevalence of seropositivity is likely much higher than the reported prevalence rates based on confirmed COVID-19 cases in Iran. Despite the high seroprevalence rates in a few cities, the low overall prevalence estimates indicate that a large proportion of population is still susceptible to the virus. The similar seroprevalence estimates between low and high-risk occupations might be an indicator of inadequate or low adherence to infection control measures among general population. Funding Statement: Iranian Ministry of Health and Medical Education COVID-19 Grant (number 99-1-97-47964). Declaration of Interests: None to disclose. Ethics Approval Statement: Ethics approval for this study was granted by Vice-Chancellor in Research Affairs-Tehran University of Medical Sciences (IR. TUMS.VCR.REC.1399.308)

Mesenteric ischemia is a rare disease with a high rate of mortality because of the non-specific symptoms which lead to delay in diagnosis and intervention. The main symptom is abdominal pain, which has a broad list of differential diagnoses. This study introduces a 17-year-old girl who presents to the emergency department with severe abdominal pain and hematemesis. Further evaluations revealed thrombosis in the mesenteric vein which leads to ischemia and gangrene of the small intestine. Her past medical history and drug history were negative, except she was taking levonorgestrel and cyproterone acetate for a 5 months period. Since long-term treatment with oral contraceptive pills, counts as a risk factor for venous thrombosis, this case seems to be uncommon. © 2019 Tehran University of Medical Sciences. All rights reserved. Acta Med Iran 2019;57(7):468-470.

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.

Liver Cirrhosis is defined as the advanced stage of the liver disease which presents with loss of normal hepatic tissue and its replacement by fibrotic tissue. It leads to alteration in all liver functions including metabolic, synthetic and coagulative function. Besides, accumulation of toxins may alter mental status.

BACKGROUND 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.

Introduction: Nonalcoholic fatty liver disease (NAFLD) is raising prevalence among children, and adolescence population in developed and developing countries as a major public health concern. The present study aims to determine the relationship between serum ferritin level and transient elastography findings in patients suffering from NAFLD. Materials and Methods: The demographic and biochemical profile of included individuals such as body mass index, age, level of serum transaminases, fasting blood sugar, lipid profile, and serum ferritin level were determined and a transient elastography was performed for all of them. Results: The mean serum ferritin level among men with mild and advanced liver stiffness was 154 ± 97 and 244 ± 214, respectively (P < 0.001), which showed a meaningful relationship. These figures among female patients with mild and advanced liver stiffness included 79 ± 91 and 161 ± 103, respectively (P = 0.003) and again revealed a significant relationship. The cutoff values of ferritin with 90% accuracy for differentiation of mild from advanced liver stiffness among male and female patients were determined as 255 ng/ml and 135 ng/ml, respectively. These cutoff values for ruling out of advanced liver stiffness with 90% accuracy among both sexes were 72.5 ng/ml and 65.5 ng/ml, respectively. Conclusion: The finding of this study revealed a significant relationship between serum ferritin level and liver stiffness among NAFLD patients, and if these results repeated in further investigations, it could be advisable to measure serum ferritin level for predicting possibility of advanced liver fibrosis.

Background and aim Many of the treatment regimens available for hepatitis C include sofosbuvir. Unfortunately, sofosbuvir has not been recommended for use in patients with severe renal impairment leaving these group of patients with very few options. Nevertheless, there are many reports in which these patients have been treated with sofosbuvir-containing regiments without important adverse events. This study aims at determining the safety and effectiveness of a sofosbuvir-based treatment in patients with severe renal impairment, including those on hemodialysis. Method We enrolled subjects with hepatitis C and estimated glomerular filtration rate under ml/min/1.73m2 from 13 centers in Iran. Patients were treated for 12 weeks with a single daily pill containing 400-mg sofosbuvir and 60-mg daclatasvir. Patients with cirrhosis were treated for 24 weeks. Response to treatment was evaluated 12 weeks after end of treatment (sustained viral response [SVR]). ClinicalTrials.gov identifier: NCT03063879. Results A total of 103 patients were enrolled from 13 centers. Seventy-five patients were on hemodialysis. Thirty-nine had cirrhosis and eight were decompensated. Fifty-three were Genotype 1, and 27 Genotype 3. Twenty-seven patients had history of previous failed interferon-based treatment. Three patients died in which cause of death was not related to treatment. Six patients were lost to follow-up. The remaining 94 patients all achieved SVR. No adverse events leading to discontinuation of medicine was observed. Conclusions The combination of sofosbuvir and daclatasvir is an effective and safe treatment for patients infected with all genotypes of hepatitis C who have severe renal impairment, including patients on hemodialysis.

Objectives: This study was conducted to evaluate the efficacy of a combination therapy using aspirin (also known as acetylsalicylic acid (ASA)) and atorvastatin in comparison with atorvastatin alone to improve liver fibrosis and function in patients with cryptogenic cirrhosis. Methods: In this randomized double-blinded clinical trail, 40 patients with cryptogenic cirrhosis were randomly allocated to the intervention group (atorvastatin + ASA) and the control group (atorvastatin) treated for six months. Then liver function and stiffness (based on transient electrography) were compared. A checklist was used for data collection and the results were analyzed by SPSS 24 using chi-square test and paired t-test at the 0.05 significance level. Results: A total of 33 cases, including16 patients in group A (atorvastatin + ASA) and 17 in group B (atorvastatin + placebo) with a mean age of 50.3 ± 11.2 and 47.9 ± 10.6 years and BMI of 30.7 ± 4.2 and 30.8± 3.1 in groups A and B, were studied, respectively. Twelve patients (75%) in group A and 14 cases (82%) in group B were male. Both groups were homogenized in terms of demographic information at baseline. A significant improvement in Child score (P = 0.001 and P = 0.002 for groups A and B, respectively) and liver stiffness (P < 0.0001 and P = 0.007 for groups A and B, respectively) were observed in both groups after the intervention, however there was no significant improvement in child score (P = 0.982) and liver stiffness (P = 0.611) in comparing both groups. Conclusions: Although atorvastatin is effective in improvement of liver fibrosis and function in cryptogenic cirrhosis, adding ASA cannot improve its effects.

Background: Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease. There is no definitive treatment for this, and prevention and treatment via diet and weight loss have been recommended. Objectives: This study aimed to investigate the effect of Dava Al-Balgham, as one of the traditional medicine products, in patients with NAFLD. Methods: The study was a randomized, double-blinded, placebo-controlled trial performed among 76 patients with NAFLD in a university-affiliated hospital, Qom, Iran, in 2017. The individuals were assigned into two groups of intervention (receiving Dava Al-Balgham; n = 37) and placebo (n = 39), using the randomized block allocation method. Both groups maintained the same diet and lifestyle. In the intervention group, two tablets of Dava Al-Balgham (a combination of Nigella sativa, Zataria multiflora, Pistacia lentiscus, and Trachyspermum ammi) were consumed with each meal for three months. In the other group, placebo tablets were used in the same manner. Pre- and post-intervention weight, waist circumference, and liver enzyme levels were measured. Chi-square, t-test, and analysis of covariance were used for comparing the two groups. Results: The levels of liver enzymes, weight, and waist circumference decreased in both groups. The mean reduction in alanine transaminase (ALT) in the intervention group was 22.80, while it was 1.59 in the placebo group (P = 0.008). The mean weight loss in the intervention and placebo groups was 2.69 kg and 0.9 kg, respectively (P = 0.003). Moreover, the mean reduction in waist circumference in the intervention and placebo groups was 3.43 cm and 0.33 cm, respectively (P = 0.001). Conclusions: Dava Al-Balgham tablets with the weight loss and hypolipidemic effect of its components can be used to help the prevention and treatment of NAFLD.

Background: Migraine is a common disorder which affects quality of life. There has been an increasing interest for discovering the association of gastrointestinal (GI) disorders with migraine during past years. This study aims to evaluate the association of Helicobacter pylori contamination, gastroesophageal reflux disease (GERD), gastric ulcer (GU), and duodenal ulcer (DU) with migraine in patients who underwent upper GI endoscopy due to refractory dyspepsia. Materials and Methods: In this observational cross-sectional study, 341 dyspeptic patients who underwent upper GI endoscopy in Shahid Beheshti Hospital, Qom, Iran, included during 2016–2018. A checklist was used for collecting demographics, symptoms, and results from endoscopy and H. pylori testing. Diagnosis of migraine was made according to the International Headache Society criteria in patients who had headache. Data were analyzed using Chi-square and independent samples t-tests in SPSS 16 (SPSS Inc., Chicago, IL, USA) with P < 0.05 as significance level. Results: Among 341 patients, 141 (% 41.3) were male and 200 (58.7%) were female. 149 (43.7%) patients were diagnosed with migraine, from which 48 (32.2%) were male and 101 (67.8%) were female. The observed difference in migraine prevalence among male and female was statistically significant (P = 0.003). 198 (58.06%) patients were H. pylori contaminated, among these 138 (69.7%) suffered from migraine. Among 143 H. pylori-negative patients, there were 11 (7.7%) migraineurs. The difference in the prevalence of migraine among H. pylori positive and negative patients was significant. H. pylori and GERD were associated with migraine with P < 0.001. Patients with DU were more commonly suffering from migraine (P = 0.001). The association in patients with GU was not statistically significant (P = 0.863). Conclusion: Migraine might be associated with GERD, H. pylori infection, and DU, and the treatment of the underlying GI disorder may control headaches.

BACKGROUND: Although stenting for the treatment of large and multiple common bile duct stones has been acceptable to everyone, its efficacy and outcome have not been studied in comparison with other endoscopic procedures. The purpose of this study was to compare the consequences of stenting and endoscopic papilla balloon dilatation for the treatment of large and multiple common bile duct stones. METHODS: In a double-blind clinical trial, of 431 patients with bile duct stones referred to the treatment center, 64 patients with multiple common bile duct stones (≥3) and more than 15 cm were selected for the study, then by random allocation rule the participants were allocated in two groups. They were entered into two different endoscopic papillary balloon dilatation (EPBD) and common bile ducts stenting treatments so that both procedures were performed by a person. Both groups were assessed from the point of views therapeutic outcomes such as duct cleaning, pancreatitis, isolated pain, and duct rupture. Data were collected by a self-made questionnaire that was used before and after the procedure to obtain the needed information. Then data were analyzed using SPSS software version 22 and descriptive and analytical tests were used as appropriated. RESULTS: Although the duct cleaning and the complete removal of the stones in the stenting treatment procedure was 93.8%, and in EPBD was 78.3%, no significant difference was observed between the two groups ( p =0.14). Pancreatitis significantly increased after the first and second endoscopic retrograde cholangiopancreatography (ERCP) in the stent group compared with EPBD ( p =0.02). Also, the most frequent cases of isolated pain were in the endoscopic group EPBD ( p =0. 0). However, the occurrence of perforation after first ERCP and EPBD was zero, but in the second stage of ERCP, 3.3% of the patients had perforations ( p = 0.99). The results indicated that the shape of the stone (circular and angled) was not effective in the result of treatment in the two groups. CONCLUSION: The results of this study indicated that in case of experience and skill in conducting the ERCP, common bile duct stenting is still the first line of treatment for large and multiple stones of the common bile ducts. KEYWORDS: s CBD stone, Endoscopic treatment of EPBD, CBD stenting, ERCP

Background: Liver fibrosis and related hepatic dysfunction are among major medical issues in patients with chronic hepatitis B (CHB). It finally may lead to cirrhosis, hepatocellular carcinoma (HCC), and liver-related death. Objectives: This study aimed to investigate the effects of adding atorvastatin to the standard antiviral therapy on the hepatic fibrosis and progression of cirrhosis in CHB patients. Methods: In this double-blinded clinical trial, 77 CHB patients referring to the gastroenterology and hepatology clinics in Qom, Iran, were selected by simple random sampling from 2016 to 2017. The participants were randomly divided into an intervention group that received tenofovir (300 mg) with atorvastatin (20 mg) daily and a control group that received tenofovir (300 mg) and placebo of atorvastatin daily. Results: According to the findings, changes in the aspartate aminotransferase (AST) level were not significant in the control (P = 0.771) and intervention (P = 0.266) groups. Changes in the alanine aminotransferase (ALT) level were non-significant in the control group (P = 0.893) but significant in the intervention group (P = 0.018). Changes in the liver fibrosis were significant in the intervention group (P = 0.001) and between the two groups (P < 0.001). Conclusions: According to the study results, adding atorvastatin to the standard antiviral regimen improves the liver function and reduces liver fibrosis in CHB patients. Therefore, it is suggested that atorvastatin be used as complementary therapy.

BACKGROUND The combination of sofosbuvir and daclatasvir is a potent, pangenotypic regimen suitable for mass-scale hepatitis C treatment, especially in resource-limited countries where newer, expensive combinations are not available. This combination has been widely tested on genotype 4. However, Phase III trials of this combination in other genotypes have been cost prohibitive. With the introduction of generic, low-cost sofosbuvir and daclatasvir, large-scale studies in resource-limited countries are now possible. METHODS Sofosbuvir at 400 mg and daclatasvir at 60 mg were coformulated into a fixed-dose combination (FDC) tablet (Sovodak, Rojan Pharma, Tehran, Iran). Patients from 46 centers were dosed for 12 or 24 weeks with or without ribavirin, in line with existing guidelines. Responses to treatment were evaluated 12 weeks after the end of treatment (for a sustained virological response at Week 12; SVR12). RESULTS There were 1361 patients recruited. Overall, the patients were 21% female, with a mean age of 50 years; 39% were cirrhotic; 22% were treatment-experienced; 47% were genotype 1, 41% were genotype 3, and 2% were other genotypes. The genotype was not known in 10% of the patients. The intention-to-treat and per-protocol SVR12 rates were 94.7% and 98.8%, respectively. The safety profile was unremarkable, treatment was well tolerated, and compliance with the single-tablet regimen was excellent. CONCLUSIONS The treatment with FDC of sofosbuvir and daclatasvir achieved high SVR12 rates, equivalent to those seen in Phase III trials of other pangenotypic options, and has been conducted at a similar scale in a representative, real-world population at a cost of under $100 per patient, which makes this combination suitable for elimination protocols in resource-limited countries. CLINICAL TRIALS REGISTRATION NCT03200184.

A 37-year-old man presented with chronic non-specific gastrointestinal tract symptoms including rectal bleeding. Colonoscopic examination showed a mass-like lesion in the descending colon with ulcerated surface. However, the pathological examination of biopsy taken from the lesion did not reveal any neoplastic process. Abdominopelvic computed tomography scan showed a giant transverse colon lipoma with suspicious feature of intussusception in descending colon which had a mass-like appearance on colonoscopy. The patient underwent surgical intervention, with a successful recovery after surgery. Key words : Adult colocolic intussusception, Gastrointestinal lipoma, Intussusception

Introduction Crohn’s disease (CD) is an inflammatory disease with an increasing incidence and can involve any part of the gastrointestinal tract. Most cases are seen in young adults presenting with abdominal pain and diarrhea. This condition may lead to complications such as stricture and fistula. Besides, there is an increased risk of colorectal cancer and some extraintestinal cancers in these patients, due to chronic inflammation. One of the therapeutic options for Crohn’s patients is the use of immunomodulators. Such agents can induce remission and limit the usage of steroids. According to some literature, this treatment can increase the risk of colorectal cancer as well as extraintestinal cancers, of which skin cancers and lymphoma are the most prevalent. Lymphoma can be a result of chronic inflammation or use of immunomodulators such as azathioprine and 6-mercaptopurine (6-MP). Case Presentation In this literature, we describe a young man with rectorrhagia who is diagnosed with Crohn’s disease and a coexistence of lymphoma at the time of diagnosis, without a history of immunomodulator therapy. Conclusions With attention to the increased risk of colorectal and extraintestinal cancer in Crohn’s patients, assessment for early diagnosis should be considered

Introduction The evaluation of acute abdominal pain must be efficient to prevent any delay in the treatment of patients, who are seriously ill, and over treatment of patients with self-limited disorders. One of the uncommon reasons that should be considered in the differential diagnosis of acute abdominal pain, especially among elderly patients, who are under anti-coagulation therapy, is abdominal wall hematoma. Case Presentation The case was a 60-year-old female with abdominal pain in the left upper and lower quadrant, which was followed by a series of coughs. She was receiving subcutaneous heparin, which was then changed to warfarin. The patient also had an episode of similar pain, one month ago and was diagnosed as abdominal hematoma based on ultrasonography report. An abdominal CT scan showed a mass lesion and the patient was diagnosed as acute on chronic abdominal wall hematoma. Conclusions Anterior abdominal wall hematoma should be considered in the differential diagnosis of acute abdominal pain among elderly patients, especially those who are under anti-coagulation therapy. Conservative treatment is conceivable in most cases and early diagnosis is compulsory to avoid morbidity or unnecessary surgery.

BACKGROUND This study is the first study to evaluate the nonadherence rate and reasons of same patient with inflammatory bowel disease (IBD) in Iran. METHODS 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.

We present preliminary results obtained using a time domain wave-based reconstruction algorithm for an ultrasound transmission tomography scanner with a circular geometry. While a comprehensive description of this type of algorithm has already been given elsewhere, the focus of this work is on some practical issues arising with this approach. In fact, wave-based reconstruction methods suffer from two major drawbacks which limit their application in a practical setting: convergence is difficult to obtain and the computational cost is prohibitive. We address the first problem by appropriate initialization using a ray-based reconstruction. Then, the complexity of the method is reduced by means of an efficient parallel implementation on graphical processing units (GPU). We provide a mathematical derivation of the wave-based method under consideration, describe some details of our implementation and present simulation results obtained with a numerical phantom designed for a breast cancer detection application. The source code of our GPU implementation is freely available on the web at www.usense.org.

A 73-year-old woman was admitted to evaluate for iron deficiency anemia, increased serum creatinine, and ascites. Her colonoscopy revealed a polyp at the junction of sigmoid and descending colon, and after polypectomy, a 6 mm colonic perforation was seen. The perforation was detected by radiography and CT scan; and beside conservative management and antibiotics, her perforation was closed by using Endoclip. The patient was observed and discharged from hospital without any surgery 5 days later, and in follow-up there was no problem regarding perforation. Resumo: Mulher, 73 anos, internada para avaliação para anemia ferropriva, com aumento da creatinina sérica e ascite. A colonoscopia revelou um pólipo na junção dos colos sigmoide e descendente e, em seguida à polipectomia, foi observada uma perfuração de 6 mm no cólon, comprovada por radiografias e tomografia computadorizada. Além do tratamento conservador e da antibioticoterapia, a perfuração foi ocluída com Endoclip. A paciente ficou sob observação e recebeu alta do hospital sem qualquer cirurgia 5 dias mais tarde. Durante o seguimento, não foram observados problemas com relação à perfuração. Keywords: Polypectomy, Colonic perforation, Endoclip, Palavras-chave: Polipectomia, Perfuração de cólon, Endoclip