Gastroenterology and Hepatology from Bed to Bench

Aim: To investigate association between MTHFR gene polymorphism with colorectal cancer.

Background: The enzyme 5,10-methylene-tetrahydrofolate reductase (MTHFR) is linked to DNA methylation, synthesis and repair. One of the most important polymorphisms that has been identified in the MTHFR gene is C677T. The single nucleotide polymorphism C677T has been found to be associated with decreased enzyme activity and decreased plasma folate. Thus it might play an important role in the etiology of colorectal neoplasia.

Patients and methods: Using pyrosequencing, we analyzed the MTHFR genotypes in 234 colorectal cancer patients and 257 normal matched controls.

Results: Whereas the CC, CT and TT genotypes of MTHFR among the colorectal cancer patients were 50%, 29% and 21% respectively, we found 36.6% of 677CC, 31.1% of 677CT and 32.3% of 677TT in the normal controls. We observed a decreased risk of colon cancer when folate intake was high for participants with wild type genotype. This association was stronger at higher levels of folate intake.

Conclusion: Our study corroborates previous findings of an inverse association of the MTHFR 677TT genotype with colorectal cancer, especially at high levels of folate.

Aim:  To evaluate the anxiety level and patient satisfaction during colonoscopy in patients who received intravenous sedation and also to determine the main predictors that may influence the anxiety level related to colonoscopy.

Background: Intravenous sedation may play a major role in reducing patient anxiety during colonoscopy and increasing the patient's satisfaction.

Patients and methods: Seventy patients scheduled for diagnostic colonoscopy were categorized into 2 groups matched for sex, age, and indication of colonoscopy. The patients in the first group were sedated with midazolam 0.1 mg/kg intravenously and the patients in the second group received saline as placebo. The level of satisfaction was evaluated on a 5-point scale (poor, fair, good, very good, and excellent) and the severity of anxiety was rated on a 100 mm visual analogue scale with "not at all anxious" and "extremely anxious" as anchors.

Results: No significant difference was found in the level of post-procedure satisfaction between the sedated and         non-sedated groups (P=0.720). The mean of anxiety score in sedated patients was significantly lower than another group (47.6±25.9 versus 74.4±16.3, respectively, P<0.001). History of colonoscopy was an important predictor for the increase of anxiety related to colonoscopy (?=15.2, SE=7.1, P=0.037).

Conclusion: Sedation can reduce anxiety during colonoscopy, but post-procedure patient's satisfaction is not dependant to sedation use.

Aim: To determine the associated factors of reflux duration, using quantile regression model.

Background: Reflux is one of the most prevalent gastrointestinal disorders.  Statistical tools are widely used to assess the associated factors on reflux severity and frequency.

Patients and methods: A door to door questionnaire has been used to evaluate gastrointestinal symptoms including reflux and heartburn between May and December 2006 in Tehran. A total of 790 adult patients with gastrointestinal problems were selected using random sampling method. Among them 208 persons were found to have heartburn. A quantile regression was employed to assess the associated factors and the results were compared to linear regression and Cox semi parametric model.

Results: Heartburn duration had dramatically high negative skewness. Quantile regression analysis indicated significant increase in the given decile of heartburn duration associated with a unit increase in given patient characteristic containing sex, pain severity and pain after having some specific food. The results from linear regression and Cox model showed poor reliability in comparison to Quantile regression.

Conclusion: The results have demonstrated that using quantile regression leads to better interpretation and richer inference about association between heartburn duration and patient characteristics.

Aim: To evaluate the association between body mass index (BMI) and certain digestive symptoms and signs.

Background: Obesity is of substantial health significance all over the world, and it is categorized by the world health organization among top ten global health problems. There is much evidence that indicates a higher prevalence of digestive symptoms in obese people.

Patients and methods: This cross-sectional study was conducted in city of Tabriz in north-west of Iran. One-thousand and seventy-one families with 4225 members were randomly selected. The association of digestive symptoms and signs with BMI was assessed.

Results: Of 4225 family members, 2485 who were above 18 years old agreed to participate in the study. The prevalence of obesity was 20.1%, and 33.3% were overweight.  There was a positive relation between increased BMI and specific digestive symptoms. Constipation (P=0.043), bloating (P=0.03), dysphagia (P=0.024), protruding anal mass (P<0.001) were more prevalent among the obese compared to normal weight participants and significant associations were found between high BMI and these symptoms. Hepatomegaly (P=0.017), abdominal tenderness (P=0.004) and tenderness on deep abdominal palpation (P=0.013) were positively associated with increased BMI in the obese. No participant was taking any anti-obesity medication.

Conclusion: In our community, increased BMI is associated with increased digestive symptoms and signs such as constipation, bloating, dysphagia, anal mass, hepatomegaly, and abdominal tenderness in deep palpation.

Aim: The aim of this study was to assay the most common signs, symptoms, and positive paraclinical findings in pancreatic cancer.

Background: It seems that the most available method for early diagnosis of pancreatic cancer is using clinical history and especially appearance of early signs and symptoms.

Patients and methods: In this descriptive study, all pancreatic cancer patients referred to Taleghani Hospital between 2000 and 2006 were included. Data were gathered from medical charts and entered to SPSS software.

Results: In total, 50 patients with pancreatic cancer (60% male and 40% female) during six years were included in the study. The most frequent age was the seventh decade (62%). The most common signs and symptoms were weight loss (82%), abdominal pain (78%), jaundice (74%), and itching (28%), respectively. The most important laboratory findings included anemia (58%), increased level of bilirubin (66%), and abnormal LFTs (70%). The ultrasound and CT scan findings had abnormalities in all cases (100%). The reports of ERCP had abnormalities in 79% of patients. There were no abnormal findings in 70% of endoscopic investigations.

Conclusion: In our study, the most common findings in signs and symptoms were weight loss, abdominal pain and jaundice, which mostly appear in advanced stage of pancreatic cancer. In addition, laboratory findings are usually nonspecific. The imaging evaluation of the pancreatic cancer is usually done in advanced stage of disease. Therefore, it is suggested to study populations, especially high-risk populations, for early signs and symptoms of pancreatic cancer for decreasing the mortality and increasing the survival of these patients.

Aim: To evaluate the diagnostic value of Helicobacter pylori stool antigen test before and after eradication

Background: There are different methods for diagnosis and follow up of Helicobacter pylori infection, including invasive methods done with endoscopy and non invasive ones such as UBT and urine analysis antibody. One of non invasive new methods is analysis of Helicobacter pylori stool antigen, used for primary diagnosis and post eradication follow up.

Patients and methods: A total of 54 patients with epigastric discomfort referred to Taleghani hospital for upper gastrointestinal endoscopy were enrolled in this study. Helicobacter infection was confirmed with rapid urease test, culture and histological methods. Gold standards for positive infection were positive culture or positive RUT and histology. Patients with positive infection (26 patients) were treated with omeprazol, tetracycline, metronidazol, bismuth subsalsylate, for 2 weeks, and then 1 and 3 month later were reevaluated with gold standard tests and Helicobacter pylori stool antigen test.

Results: Sensitivity, specificity and accuracy of Helicobacter pylori stool antigen test were 78.6%, 92.3%, and 85.2% respectively before eradication, 100% and 56.5% and 61.5% 1 month after eradication and 85.7%, 89.5% and 88.5%, 3 months after treatment.

Conclusion: Helicobacter pylori stool antigen test is an excellent method for pretreatment diagnosis of Helicobacter pylori infection, and also in 3-month follow up of eradication, but the specificity and accuracy were low in early period follow up.

Aim: To assess the complications of bile duct injury in laparoscopic cholecystectomy in Loghman medical center, Tehran.

Background: The incidence of complications of laparoscopic cholecystectomy has increased dramatically since the introduction and widespread use of laparoscopic cholecystectomy. 

Patients and methods: From January 1998 to January 2002, a total of 155 laparoscopic cholecystectomies were performed at the Loghman medical center. A retrospective analysis of complications including major bile duct injuries, cystic duct leakage, and bile duct strictures, was carried out.

Results: Of 155 patients with cholelithiasis, conversion to open cholecystectomy was required in 20 patients (13%).  There were 3 (2.22 %) major bile duct injury in laparoscopic cholecystectomy that required reconstructive operations at later stage.

Conclusion: Laparoscopic cholecystectomy is an operation associated with low morbidity and mortality rate, but bile duct injury is still a major problem. Clear demonstration of anatomy is the cornerstone of safe, successful laparoscopic cholecystectomy.

Background: Common Variable Immunodeficiency (CVID) is associated with a broad spectrum of symptoms related to infections, chronic lung diseases, autoimmune diseases, and tumors; however, solid tumors are rare complications of CVID and gastric cancer, specially, has been reported very rarely.

Case Presentation: The present case report describes a 28 years old known case of CVID male, who was referred to us because of chronic diarrhea, weight loss and abdominal pain. He had history of recurrent respiratory infections but first manifestations of his recent problem had appeared six months before the referral as epigastric pain, vomiting, and watery diarrhea.

During his initial workup the patient had undergone partial gastrectomy surgery because of the pyloric stenosis. In early assessment of patient in our center, an ulcerative mass lesion with induration and regidity in body and antrum of stomach was seen during upper GI endoscopy. Endoscopic ultrasound evaluation revealed thickening in body layers, expansion of tumor in 3^rd and 4^th   layers, and 2-3 perigastric lymphadenopathy. Eventually, undifferentiated adenocarcinoma of the stomach was reported by histologic examination.