ISSN: 2008 - 2258

Review Article

The Role of Artificial Intelligence in Colon Polyps Detection

Pezhman Rasouli, Arash Dooghaie Moghadam, Pegah Eslami, Mohammad Reza Zali, Morteza Aghajanpoor Pasha, Hamid Asadzadeh Aghdaei, Amir Nezami Asl, Azim Mehrvar, Shahrokh Iravani, Amir Sadeghi

Gastroenterology and Hepatology from Bed to Bench, , 2 June 2020

Over the past few decades, artificial intelligence (AI) have evolved dramatically and is believed to have a significant impact on all aspect of technology and daily life. The use of AI in health care system has been rapidly rising, owing to the large amount of data. Various methods of AI including machine learning, deep learning and convolutional neural network have been used in diagnostic imaging that could help physicians to achieve accurate diagnosis and determining the appropriate treatment of diseases. Using and collecting huge number of digital images and medical records have led to create big data over a time period. Currently, considerations regarding the diagnosis of various presentations in all endoscopic procedures and imaging findings are solely handled by endoscopists. On the other hand, AI has shown to be highly effective in the field of gastroenterology in terms of diagnosis, prognosis, and image processing. Herein, this review aimed to discuss about different aspects of AI usage for early detection and treatment of gastroenterology diseases.

Original Article

Risk of relapse and death from colorectal cancer and its’ related factors using non-Markovian Multi-State model

Saeideh Hajebi Khaniki, Vahid Fakoor, Soodabeh Shahid Sales, Habibollah, Esmaily, Hamid Heidarian Miri

Gastroenterology and Hepatology from Bed to Bench, , 2 June 2020

Background: Modeling the course of cancer regarding events happen to patient is of great importance. The objective of this study was to study risk of local relapse and death from colorectal cancer after the first treatment and its related factors using multi-state models.

Study design: A historical cohort study.

Methods: 235 patients with colorectal cancer who referred to Omid Hospital in Mashhad between 2006 and 2011 were studied and followed up to 2017. Data included individual and clinical variables. The transition probabilities to death due to metastasis with or without experiencing local relapse and variables related to them were determined using non-markovian multi-state model with three state of disease, local relapse and death. R 3.5.2 was used for statistical.

Results: The probability of not experiencing neither of events, just relapse and death in the first 5 years were 0.45, 0.09 and 0.46 respectively. Also, if patient had not experience any event until one year after first treatment, the probability of relapse and death until the fifth year were 0.04 and 0.33 respectively and if he experienced relapse during the first year of treatment, the probability of his death by the fifth year was 0.62. Stage of cancer was associated with relapse and death, while ethnicity and history of addiction were related to death without relapse and BMI had significant effect on death after relapse (p<0.05).

Conclusion: Risk of death in patients having colorectal cancer depends on local relapse and the time between them.

Background and Objective: Cancer is the leading cause of death and the most important barrier to increase life expectancy in the world. Colon cancer is the fourth cause of cancer and the fifth cause of cancer death in Iran. The aim of this research was to evaluate the demographic, pathological and clinical characteristics of the patients with colon cancer and evaluate the survival rate and its related factors.

Materials and Methods: In this descriptive-analytical study, 219 patients with colon cancer who referred to Imam Khomeini Hospital in Sari during the years 2012-2017, were investigated. The required information was extracted from the patients' medical records. Data were analyzed through descriptive and univariate methods using R software. Kaplan-Meier survival analysis and log-rank test were used to evaluate survival.

Results: In the present study, the ratio of males to females was 1.3: 1. The mean age of the patients’ diagnosis was 59.3 ± 15.39 years and 13% were at the age range of less than 40 years old. Family history of cancer was positive in 30% of patients and they had a mean age less than those with negative family history (p = 0.001). According to the clinical symptoms of the patients based on the site of tumor involvement, rectorrhagia was significantly higher in the patients with sigmoid tumor site (p <0.001) and abdominal pain was higher in the patients with transverse and ascending tumor sites (p<0.001).  Anemia was significantly higher in the patients with ascending and caecum tumor sites (p = 0.01). Half of the patients were in advanced stages. Tumor morphology in most cases (86%) was adenocarcinoma and had a higher mean age (60.84 ± 14.67) than mucinous adenocarcinoma (48.1 ± 16.65) (p = 0.002). The rate of local recurrence was 33% and it was more in stage D (p = 0.03). Metastasis was seen in 34% of patients and the most common site of metastasis was liver. Median and mean life expectancy of the patients were 60 and 53.71 ± 2.07 months, respectively. Three-year, five-year, and seven-year survival rates were 70, 49, and 37 %, respectively. Five-year survival rate at A, B, C, and D stages of the disease was calculated to be 83%, 67%, 44% and 6%, respectively. Survival in these patients was significantly correlated with clinical symptoms at the time of diagnosis, rate of tumor differentiation, lymph node involvement, tumor stage, and metastasis to other organs (p <0.05).

Conclusion: 30% of patients had positive family history. Half of the patients were diagnosed at advanced stages of the disease and the mean survival time at advanced stages was approximately four years. Almost one-third of patients had local recurrence. It is recommended for patients to refer at specified time intervals for timely diagnosis of the disease and prevention of its recurrence. Providing effective trainings for people to gain more knowledge on colorectal cancer, paying attention to gastrointestinal symptoms in patients, and performing screening tests will lead to early diagnosis and lower mortality.

The correlation between vitamin D levels and demographics in patients with gastrointestinal disorders; A cross-sectional study.

Suhaib JS. Ahmad, Ahmed R Ahmed, Jafer Ali, George Macfaul, Matt W Johnson, Aristomenis K. Exadaktylos, Rami Archid, Sami Ahmad, Hamid Mohaghegh, Mohammad Rostami-Nejad, Ravi Madhotra, Kamran Rostami

Gastroenterology and Hepatology from Bed to Bench, , 2 June 2020

Aim: The aim of this study is to evaluate vitamin D levels, in correlation with age, body mass index (BMI), gender and ethnicity, in patients with gastrointestinal disorders (GID).

Background: Vitamin D deficiency (VDD) is a global health issue, affecting over 1 billion people. A great body of evidence has shown that it can lead to an increased morbidity and mortality. Contrarily, latitude, sedentary lifestyle, limited sunlight exposure, ageing and the presence of comorbidities and chronic illnesses, places patients at an increased risk of VDD. 

Materials and methods: 305 Consecutive patients, with GID, were assessed for vitamin D levels, using a two-step competitive binding immunoenzymatic assay. Patients were then classified as adequate (50-150nmol/l), insufficient (25-50nmol/l) and deficient (<25nmol/l).

Results: 62% of investigated subjects had low vitamin D levels. From this group132 patients (43.3%) had insufficient vitamin D levels, 57 (18.7%) had deficient levels and 116 (38%) had adequate levels. Age was not significantly different in the 3 groups (p=0.29). Interestingly, Vitamin D levels were significantly lower in men (39.23±23.62) compared to women (50.68±24.46) (p=0.0001). The BMI was significantly higher in patients with insufficient vitamin D levels. The Asian ethnicity had a positive influence on vitamin D levels (B=0.076) (p<0.0001). 71.4% of patients, with IBD, and 60% of patients, with abnormal liver function, had low vitamin D levels. 

Conclusion: VDD has a high prevalence, in patients with GID in particular IBD and liver disease in United Kingdom. Routine vitamin D testing and supplementations in case of deficiency and suboptimal level of vitamin D for patients with hepatobiliary, pancreatic, kidney, malabsorptive and restrictive diseases/surgeries is recommended. 


Determination of optimal time for reading of rapid urease test diagnosis of Helicobacter pylori

Alireza Eslaminejad, Seyed Mehran Marashian, Maryam Aboutorabi, Makan Sadr, Shahram Agah

Gastroenterology and Hepatology from Bed to Bench, , 2 June 2020

Background: Rapid urease test is obviously known as an accurate test for H-pylori detection in tissue biopsies. The current diagnostic study headed to find the best reading time for the best accuracy for RUT in optimal time to get faster results with lower false rates and save time to start treatment in peptic ulcer.

Materials and Methods: Patients with GI problems referring to a university hospital in Tehran who underwent endoscopy and biopsy in 2013 enrolled the project and three samples of mucosal tissue were captured from the lesser curvature, the antrum and the body of stomach.

Results: We found 39.6% sensitivity and 95% specificity for the named test in first 5 minutes as well as PPV = 95.5% and NPV = 37.3% while the accuracy was 54.79% (table2). Except the specificity which was constantly 95% in all RUT reading times, other diagnostic parameters were growing as time went on. The PPV was also higher than 97% after 10 minutes. The most values of sensitivity, specificity, PPV, NPV and accuracy were achieved after 12 hours including 88.7%, 95%, 97.9%, 76% and 90.41%, respectively.

Conclusion: To conclude, it seems that there are many different ideas in terms of rapid urease test in H.pylori detection. However, the current study can advise reading the test optimally after 12 hours and we also advise more multidisciplinary studies with bigger sample size to get better and much reliable results to generalize in this regard.

Epidemiological Patterns and Antimicrobial Resistance of Bacterial Diarrhea among Children in Nairobi City, Kenya

Mark Kilongosi Webale, Christine Wanjala, Bernard Guyah, Nathan Shaviya, Godwil Munyekenye, Peter Lokamar Nyanga, Immaculate Nyaseba Marwa, Sammy Kagoiya, Laura Nyawira Wangai, Sella K. Webale, Ken Kimani, Nicholas Kitungulu

Gastroenterology and Hepatology from Bed to Bench, , 2 June 2020

Background: Even though enteric bacterial pathogens are a major cause of gastroenteritis in children, their prevalence and antimicrobial resistance show regional spatial and temporal variation. Methods: This cross-sectional study investigated the aetiology and antimicrobial resistance of bacterial diarrhea among children (n=374) in Nairobi city, Kenya. Bacterial isolation and identification was performed by conventional microbiological methods. Antimicrobial resistance was determined using disk diffusion method. Results: Diarrheagenic E. coli (36.4%) was the leading species followed by Shigella (3.2%), Salmonella (2.4%), Campylobacter (1.6%), Yersinia (1.3%) and Aeromonas (1.1%) species. E. coli pathotyping revealed that 20.9%, 4.0%, 10.2% and 0.5% of the study participants were infected with EAEC, EPEC, ETEC and EIEC pure isolates while the prevalence of mixed pathotype infections was 0.3% for EAEC/EPEC/ETEC and 0.5% for EAEC/ETEC. Shigella sero-grouping revealed that 0.5%, 0.3%, 1.9%, and 0.5% were infected with Shigella boydii, Shigella dysentriae, Shigella flexneri and Shigella sonnei pure isolates. Shigella species and E. coli co-infection was detected in 2.4% of the children, specifically, 1.1% for EAEC/Shigella boydii, 0.5% for EAEC/Shigella dysentriae and 0.3% in each case of EAEC/Shigella sonnei, EPEC/Shigella flexneri and ETEC/Shigella flexneri co-infections. Most of the isolates were resistant to commonly prescribed antibiotics. Conclusion: There was a high prevalence of enteric bacterial pathogens and co-infection alters epidemiological dynamics of bacterial diarrhea in children. Continuous antibiotic resistance surveillance is justified because the pathogens were highly resistant to commonly prescribed antimicrobials.

The antidiabetic and hepatoprotective effects of Myricitrin on aged mice with D-galactose

Mina Omidi, Akram Ahangarpour, Layasadat Khorsandi, Fatemeh Ramezani- AliAkbari

Gastroenterology and Hepatology from Bed to Bench, , 2 June 2020

Aim: The aim of the present study is to evaluate the effects of antidiabetic and hepatoprotective of myricitrin in the aged mice induced by D-galactose (D-gal).

Background: Aging occurs during person’s life, there has been no way to stop the aging process, but it can be delayed by antioxidant and changing lifestyle.

Materials and methods: In this experimental study, 72 female adult mice (weighing30–35g) were randomly divided into six groups: 1: control, 2: D-gal at 500mg/kg/d, 3-5: D-gal+ Myricitrin at 5, 10 and 20mg/kg/d 6: D-gal+ Vitamin E at 100mg/kg/d. Aging induced by D-gal for 45 days via intraperitoneal. Myricitrin and Vitamin E administrated orally by gavage for the last 28days. The blood glucose, insulin level, ?-cell function, insulin resistance, hepatic enzymes, lipid profile and histology of the liver and pancreas were evaluated.

Results: D-gal injection increased glucose (p<0.001) and insulin levels (p<0.01) compared with the control group. Myricitrin (p<0.01) and Vitamin E (p<0.001) increased insulin and decreased blood glucose levels compared with the D-gal group. Myricitrin had a similar effect on insulin levels to vitamin E. Insulin resistance induced in the D-gal group (p<0.001). Myricitrin reduced insulin resistance and increased ?-cell function (p<0.01) compared with the D-gal group. The D-gal was elevated (p<0.01) cholesterol, LDL and triglyceride level, myricitrin (p<0.001) and Vitamin E (p<0.05) were reduced them.

Conclusion: D-gal-induced aging causes accumulation of RBCs, inflammation in the liver, and changes in the number and diameter of Langerhans islets in the pancreas, Myricitrin improved this D-gal effects. Myricitrin had anti-diabetic and hepatoprotective effects the aged mice induced by D-galactose.

Evaluation of Preoperative Liver Function Test Efficacy in Patient with Symptomatic Cholelithiasis

Majid Rezaei-Tavirani, Mohammad Amin Abbasi, Masoud Bagaee, Adnan Tizmaghz, Morteza Khavanin-Zadeh

Gastroenterology and Hepatology from Bed to Bench, , 2 June 2020

 Background:  Significant relationship between common bile duct (CBD) stones and acute cholecystitis is reported. There are contradictory reports about effect CBD stones on liver function tests in patients (LFTs).

Aim: It is aimed to investigate the necessity of preoperative liver function tests (LFTs) in patients with uncomplicated gallstone disease before laparoscopic cholecystectomy.
Methods: In the present study, patients with symptomatic cholelithiasis who referred to hospital during January 2015 and May 2016 were enrolled. Routine tests and ultrasonography was performed to all patients before surgery. Data were presented as means ± SD and qualitative variables as frequency (percentage) was cosidered. Statistical analyzes were performed with SPSS software.

Results: A consecutive of 270 patients (58 males and 212 females) who referred for laparoscopic cholecystectomy were enrolled in this retrospective study. Pre- operative LFTs were normal in 249 patients (85%) and abnormal LFT was detected in 41 patients (15 %).
Conclusion: This study showed that 15 % of patients with cholelithiasis without dilated CBD had impaired LFTs.  Routine LFTs in preoperative evaluation of symptomatic cholelithiasis usually reveals normal findings and is not helpful in uncomplicated cholelithiasis.

Medical Education


The present study aims to teach the right citation models in scientific publications by top authors from Iranian universities of medical sciences in 2017, considering the relationship between moral development and self-control variables and model of "citation to multi-authored papers" in these articles. This study is of applied scientometrics and correlation (model presentation) studies type. The research population in the first part of this study includes all the authors who had an H-index of 10 or more in the scientific databases of 2017. The sample size at this stage was 110, selected by systematic random sampling. The collected data were analyzed using SPSS 16.0. The results of regression analysis based on the concurrent method indicated that the regression model is significant. The coefficient of determination is 0.096 and the F ratio is 5.650, which are significant at the level of p <0.001. In this regression model, the variables of the level of moral development (? = -5.801, p <0.001) and self-control (p < 0.001, ? = -0.253) have significant predictive power and can be considered as predictors of behavioral model in citing "multi-authored papers". Based on the results, teaching how to avoid citing blindly the "multi-authored papers", which is regarded as a kind of "citation deviation", can, to some extent, lead to strengthening citation indexes.

Keywords: Citation Behavior, Self-Control, Moral Development, Multi-Authorship.


Case Report

The black esophagus and duodenum: a rare case report

Saad Saleem, Simcha Weissman, Sumair Ahmad

Gastroenterology and Hepatology from Bed to Bench, , 2 June 2020

Acute esophageal necrosis is a rare esophageal disease, typically characterized by the circumferential black appearance of the esophagus mucosa that usually affects the distal esophagus. It commonly affects the elderly man with multiple comorbidities. In medical literature, some cases have been reported about acute necrotizing esophagus, but according to our knowledge, no case has been reported about a patient with ischemic duodenum and esophagus. We describe the case of a 71-year-old man with an upper gastrointestinal bleeding and subsequently acute necrotizing esophagus and duodenum.

Duodenal angiosarcoma can misdiagnose as a Dieulafoy’s lesion

Afshin Amini, Elliot Koury, Zahra Vaezi, Jeffrey Melnick, Andrew Su, Elie Chahla

Gastroenterology and Hepatology from Bed to Bench, , 2 June 2020

Angiosarcomas are soft-tissue neoplasms that originate from the vascular epithelium. The most commonly involved sites include the skin and subcutaneous tissues. In the GI tract, generally, angiosarcomas involve the spleen and liver, while a location in the small intestine and colon has been rarely reported. We report the unusual case of a duodenal epithelioid angiosarcoma, presenting with anemia and recurrent upper gastrointestinal bleed, and initially misdiagnosed as a Dieulafoy’s lesion. It is important to consider the diagnosis of gastrointestinal malignancy, including unusual neoplasms such as angiosarcomas, in the setting of recurrent bleeding lesions that are persistent despite repeat interventions. In such cases, a biopsy should be considered to confirm the diagnosis.

Letter to Editor

Bone Health: An Important Consideration in Coeliac Disease

William Shanahan, Jayne Shanahan

Gastroenterology and Hepatology from Bed to Bench, , 2 June 2020

Dear Editor,

Shiha et al pose a contentious question in their recent article entitled “Diagnosing coeliac disease in the elderly: a United Kingdom cohort study”. They muse at the necessity for active case finding of coeliac disease in the elderly, implying that the burden of breaking nutritional habits may exceed the benefits of diagnosis. 

While one may concede that the adage “scientia potentia est” may not always hold true, we are inclined to disagree with the authors in this instance. Bone health is an important consideration both in the elderly and in those with coeliac disease, independently. It follows that this should be of particular concern in the elderly with coeliac disease. While the authors reference the need to establish the risks of not pursuing a diagnosis, we feel their suggestion belies a lack of appreciation for the potential to recognise and prevent bone related morbidity in such patients. An audit of patients within the catchment of our tertiary level hospital in the South-East of Ireland shows that such an under-appreciation may be widespread. The British Society of Gastroenterology guidelines on coeliac disease state that patients should undergo a vitamin D level check at diagnosis. On reviewing our laboratory records of patients with a positive IgA anti-tissue transglutaminase over 18 months, from January 2018 to June 2019, we found that only 14.6% of patients had vitamin D assessed within 6 months of a first positive result.

Coeliac disease is associated with an increased risk of osteoporosis and fracture, and just 1 year of adhering to a gluten free diet in such patients has been shown to lead to an improvement in objective markers of bone mineral density. In light of this, we feel the need to express our respectful disagreement with the proposal to not seek out a diagnosis of coeliac disease in the elderly. What’s more, we should be reminding our clinician colleagues of its relationship with bone disease and actively managing those patients who have multiple osteoporotic risk factors. This appears to be especially true in the case of coeliac disease given the poor compliance with guidelines in relation to vitamin D assessment in the cohort of patients within the catchment of our institution.

Informed decision making for the elderly patient with newly diagnosed coeliac disease

Mohamed G. Shiha, Lauren J. Marks, David S. Sanders

Gastroenterology and Hepatology from Bed to Bench, , 2 June 2020

Dear Editor,

We thank Dr. W.Shanahan and Dr. J.Shanahan for their interest in our study (1). In their letter, they have raised a few important points that we wish to clarify.

Firstly, they implied that we had a lack of appreciation for the recognition and prevention of bone-related morbidity in elderly Coeliac Disease (CD) patients. We respectfully disagree with their statement; throughout our paper, we repeatedly highlighted the importance of recognising such complications in this group of patients. Moreover, we reported that elderly CD patients had a significantly higher risk of osteopenia/osteoporosis compared to younger patients. In our practice, we routinely measure serum vitamin D, alkaline phosphatase and calcium levels for all CD patients and refer those older than 55 years or with known osteoporotic risk factors for bone density scan following the British Society of Gastroenterology guidelines. (2) A single centre audit, while valuable to improve local practice, should not be used to generalise poor adherence to national guidelines.

Secondly, we agree that CD is associated with an increased risk of osteoporosis and fractures. However, GFD adherence rarely reverses bone loss in adults. This particularly evident in elderly patients with long-term exposure to gluten and established bone disease at the time of diagnosis (3) (4).  In our study, 57% of the osteopenic/osteoporotic elderly CD patients were completely asymptomatic. Therefore, without strong evidence from randomised controlled trials or large prospective studies showing clear benefit from adhering to a strict GFD over nutritional supplementation only in this age group, we have to raise the question whether it is worth breaking lifetime dietary habits in asymptomatic elderly patients.

Finally, should we be diagnosing Coeliac Disease in the elderly? The answer is probably yes. However, the majority of these patients show little to no gastrointestinal symptoms and are often referred through cancer or metabolic pathways with unexplained anaemia and bone loss. Hence, the diagnosis of CD may come up as a shock to them. We feel that empowering elderly patients to adopt a GFD on an individual level based on the presence or absence of symptoms might be appropriate. Nonetheless, future research is needed to evaluate the alternatives to GFD and the other long-term risks of CD, such as malignancy and anaemia, before accepting such an approach.