Gastroenterology and Hepatology from Bed to Bench

The most complained gastrointestinal symptoms are chronic diarrhea, bloating and abdominal pain. Once malignancies and inflammatory bowel diseases are excluded, irritable bowel syndrome (IBS) and the so called “IBS-like disorders” should be taken into account. The relationship between IBS as defined by Rome IV criteria and these clinical conditions is sometimes obscure, since many IBS patients identify food as a possible trigger for their symptoms. Here, we discuss IBS and the most common IBS-like disorders (celiac disease, non-celiac gluten sensitivity, fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs), lactose intolerance, small intestinal bacterial overgrowth (SIBO), ?-amylase/trypsin inhibitor (ATIs), nickel allergic contact mucositis), focusing on epidemiologic, clinical, diagnostic and therapeutic aspects. Given the lack of specificity of symptoms, clinical investigation will be facilitated by awareness of these disorders as well as new specific diagnostic tools

Aim: We conducted a cross-sectional study to estimate the prevalence of CRD in our area in East Azerbaijan, Iran.

Background: Colorectal diseases (CRD) include a broad spectrum that varies from benign lesions to malignant and cancerous masses. CRD can be investigated by colonoscopy. Some of these diseases are highly preventable with timely screening and appropriate planning by the healthcare system.

Methods: This is a hospital-based, cross-sectional study by the Gastroenterology Department on patients who underwent colonoscopy between June 2013 and March 2015 in outpatient clinics at private Shahriyar medical center and Imam Reza University Hospital in Tabriz, East Azerbaijan province, Iran. Chi-square analysis and bivariate Pearson correlation coefficient were applied in this study using SPSS 20.

Results: During the study period, we recruited 2300 patients (1230 men, 1070 women) with the mean and median (Standard Deviation=SD) age at presentation of 47.10 (0.338) and 47 (16.195) years. The duration of patients’ symptoms ranged from 1 to 480 months, with mean and median (SD) values of 26.99 (0.902) and 12 (40.76) months, respectively. Despite at least 20 types of pathologies seen on colonoscopy, normal cases constituted the majority (32.7%).The most serious diseases in the study were IBD (10.9%), polyps (14.4%) and cancers (4.9%). Colonoscopic findings had a significant correlation with patients’ age and gender; also, we detected a significant correlation between patients’ chief complaint and colonoscopic findings as well as colonoscopic pathology samples.

Conclusion: Despite the ongoing westernization of lifestyle in our country, the distribution of colorectal diseases in Iran is different from Western population. It is important to recognize the prevalence of these diseases in our area to determine exposure factors for management and planning correctly in health system policies.

Aim: This study aims to evaluate plasma osteopontin (OPN) levels as a potential biomarker for hepatocellular carcinoma (HCC).

Background: Osteopontin (OPN) is a secreted glycoprotein that is associated with tumorigenesis and metastasis.

Methods: We measured plasma levels of OPN in 26 HCC patients, 27 patients with chronic liver diseases (CLD), and 15 healthy control individuals using a standardized ELISA kit.

Results: The mean plasma OPN level was significantly higher in the HCC group than the CLD group or the normal control group (p-value =0.001/<0.0001). Plasma OPN levels were significantly higher in patients with a tumor size >5 cm in diameter than those with tumors ?5 cm (p=0.02). OPN levels in the HCC group were not significantly affected by advancing degree of Child-Pugh class. Diagnostic sensitivity and specificity of OPN for HCC were 61% and 82%, respectively (cut-off value: 118.69ng/mL). The area under the ROC curve (AUC) value for OPN was 0.784. However, the AUC value was 0.844 for AFP.

Conclusion: The plasma levels of OPN show low diagnostic accuracy for HCC compared to AFP. However, OPN may have a complementary role in diagnosing HCC in patients with non-diagnostic levels of AFP.

Aim: The present study was conducted to survey the potential cytotoxic influence of freeze-dried aqueous extract of its fruits on gastrointestinal cell lines, namely AGS (human gastric carcinoma) and KYSE30 (human esophageal squamous cell carcinoma.

Background: Rosemary (Rosmarinus officinalis) is a wild medicinal plant shown to have anticancer activity. Carnosic and rosmarinic acids are compounds, obtained from it through several extraction methods.

Methods: The aqueous extract of the fruits of R.officinalis was freeze-dried, and KYSE30 and AGS cancer cell lines were treated with crude extract. Cytotoxic effect of the extracts on the cell lines was examined using 3-(4, 5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and neutral red assay. Apoptotic cells were detected with ethidium bromide/acridine orange (EB/AO). Cell-cycle distributions were evaluated by flow cytometry.

Results: IC50 values were 4.1, 1.8 and 1.3 mg/mL for AGS cell lines after 24, 48 and 72 hours by MTT assay, respectively, and 4.4, 2.1 and 1.1 mg/mL by neutral red assay, respectively. IC50 values for KYSE30 cell lines were 600, 180 and 150 mg/mL after 24, 48 and 72 hours by MTT assay, and 860, 270 and 230 mg/mL by neutral red. EB/AO staining increased in apoptotic cells. After 24 h of treatment at different concentrations, significant increases and decreases in population were shown at G2/M and G1 phases, respectively.

Conclusion: The aqueous extract of the fruits of R.officinalis was freeze-dried, and KYSE30 and AGS cancer cell lines were treated with crude extract. Cytotoxic effect of the extracts on the cell lines was examined using 3-(4, 5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and neutral red assay. Apoptotic cells were detected with ethidium bromide/acridine orange (EB/AO). Cell-cycle distributions were evaluated by flow cytometry.

Aim: Evaluation of the role of MLH-1 loss in serrated polyps of colon in a population of South of Iran.

Background: There has been extensive change in classification and pathogenesis of serrated polyps of the colon during the last 10 years. The new classification is mostly based on the knowledge of the molecular pathogenesis and the rate of progression to colorectal cancer in these types of polyps. One of the most common and early lesions in molecular pathogenesis of serrated colorectal cancer is loss of MLH-1.

Patients and methods: In this study over 2 years (2012-13), 78 cases of colorectal polyps with serrated morphology resected in hospitals affiliated with Shiraz University of Medical Sciences were reclassified and investigated for MLH-1 loss by immunohistochemical method.

Results: Out of the 78 colorectal polyps, 64 were classified as hyperplastic polyp (HP) and 14 as sessile serrated adenoma/polyp (SSA/P). There was no case of traditional serrated adenoma. Three cases of SSA/P located in right colon showed dysplasia. MLH-1 loss was detected only in these 3 cases. No case of HP or SSA/P without dysplasia showed MLH-1 loss.

Conclusion: SSA/P is not a common serrated polyp in our population, i.e. it is much less common than HP. Although MLH-1 loss in serrated polyps of colon is overall rare, it is fairly common in dysplastic right sided SSA/P, which confirms this molecular change as an early event in serrated carcinogenesis.

Aim: The aim of this study was to determine the effect of inhibition of TGF-?/smad signaling on the expression profiles of miR-335, miR-150, miR-194, miR-27a, miR-199a of hepatic stellate cells (HSCs).

Background: Liver fibrosis is excessive deposition of extracellular matrix proteins due to ongoing inflammation and HSC activation that occurs in most types of chronic liver diseases. Recent studies have shown the importance of microRNAs in the pathogenesis of chronic liver diseases.

Methods: In this study, for inhibition of TGF-? smad-signaling pathway, expressing Smad4 shRNA plasmids were transfected into HSCs. Subsequently, using Real Time-PCR, we measured the expression levels of miR-335, miR-150, miR-194, miR-27a and miR-199a.

Results: Gene expression analysis showed that downregulation of Smad4 by vector Smad4shRNA significantly increased the expression levels of miR-335 (P<0.01) and miR-150 (P<0.001) and decreased the expression level of miR-27a (P<0.05).

Conclusion: The results of this study suggest that blocking TGF-? smad-signaling can also differentially modulate microRNA expression in support of activation and fibrogenesis of HSCs.

Aim: The aim of this study is to present the oral Squamous Cell Cancer protein-protein interaction network interpretation in comparison to esophageal adenocarcinoma.

Background: Oral squamous cell cancer (OSCC) is a common disease worldwide, with poor prognosis and limited treatment. Thus, introducing molecular markers through network analysis can be helpful.

Methods: STRING database (DB) was applied for network construction through Cytoscape 3.4.0.  Clue GO handled the gene annotation for the retrieved clusters. Eight proteins were indicated to be differential in the network constitution.

Results: The centrality and clustering analysis indicate that TP53 plays an over-significant role in network integrity among eight most central proteins including TP53, AKT1, EGFR, MYC, JUN, CDH1, CCND1, and CTNNB1.  The suggested biomarker set is very similar to the related biomarker panel of esophageal adenocarcinoma.

Conclusion: The ontology analysis implies that the prominent proteins are involved in regulation of smooth muscle cell proliferation, regulation of fibroblast proliferation, and response to UV-A processes.  In conclusion, these proteins and their associated biological processes may be more critical compared to other reported biomarkers for OSCC. Nevertheless, validation studies are required for confirming the pivotal role of potential candidates. Similar biomarker panel of this disease and esophagus adenocarcinoma is corresponded to the origin of the two malignancies.

Aim: We hypothesize that chronic cholecystitis accounts for the majority of inflammatory diseases in the pediatric population and it is difficult to predict with preoperative ultrasound.

Background: Despite the increase in gallbladder disease, there is a paucity of data on pediatric cholecystitis.  Most pediatric studies focus on cholelithiasis and biliary dyskinesia rather than inflammatory gallbladder disease.

Methods: We performed a single center retrospective review of all patients who underwent cholecystectomy from 1/1/10 – 1/1/15. Relevant data was extracted, including age, sex, acute vs. chronic presentation, duration of symptoms, preoperative imaging findings, and surgical pathology results.

Results: Out of the 170 patients identified, there were 129 (75.9%) females and 41 (24.1%) males. The average age was 14 years (range 4-23 years). Seventy-six patients presented with acute symptoms with an average duration of pain of 2 days. Ninety-four patients presented with chronic symptoms and had an average duration of pain of 7.4 months. Eight patients (4.7%) had preoperative ultrasound that suggested inflammation, while the remaining showed only cholelithiasis. Pathology revealed chronic cholecystitis in 148 (87.1%). Among those who had pathologic evidence of chronic cholecystitis, preoperative inflammation was seen in only 5 patients (3.3%).

Conclusion: Chronic cholecystitis accounts for the majority of pediatric inflammatory diseases. These data suggest that most pediatric patients experience episodes of inflammation prior to cholecystectomy. Underappreciated gallbladder inflammation may delay surgical referral, increase emergency department and primary doctor visits, and lead to more difficult operations. Surgeons should consider early cholecystectomy when cholelithiasis and symptoms are present.

Aim: This work aims to isolate and perform comparative studies of a phages active against a Salmonella enteritidis strain from Iran. Also, suitable phage candidates for therapy of mice will be selected.

Background: Bacteriophage is of particular interest as a biocontrol agent in the prevention of food-borne illnesses. In recent years tend to use bacteriophages to control pathogenic bacteria has increased. A bacteriophage is considered to be a potent antibiotic alternative for treating bacterial infections.

Methods: the specific phages against Salmonella Enteritidis was isolated and candidates for therapy of mice will be selected. Mouses divided into the six specific groups. Groups of mice were as follows: A: Bacteri (control) B: Bacteri+ bacteriophage (Simultaneous), C: Bacteri + bacteriophage Four days later, D: Bacteriophage + bacteri four days later E: Bacteri+ Ciprofloxacin (Simultaneous) F: Bacteri+ ciprofloxacin+ bacteriophage (Simultaneous).

Results: In this study, a lytic bacteriophage is isolated and it shows that phage has a head size of 46 nm and without a tail, by using an electron microscope. Oral administration of a single dose of 2 × 109 PFU/mouse bacteriophage enable to protect mouse against salmonellosis and it causes treatment of salmonellosis in mice.

Conclusion: The use of this phage compared to ciprofloxacin shows that in addition of the treatment of mouse, it also prevents weight loss.

Aim: This cross-sectional study aims to assess the prevalence of Cryptosporidium in hemodialysis patients compared with healthy individuals in central Iran from August 2014 to January 2015.

Background: Cryptosporidiosis is a major cause of acute and persistent diarrhea with significant morbidity and mortality in immunocompromised patients such as those undergoing renal dialysis.

Methods: Three stool samples were collected from 330 hemodialysis patients and 150 healthy individuals on 3 consecutive days. The samples were screened for Cryptosporidium infection using formalin-ether sedimentation and modified Ziehl-Neelsen staining. Demographic variables as well as risk factors were recorded.

Results: Out of 330 dialysis patients and 150 healthy individuals, 10 (3%) and 1 (0.7%) were infected with Cryptosporidium, respectively. We found statistically significant differences between infection and place of residency, hygiene status, education level, diarrhea, and abdominal pain in the two groups (p<0.05). On the other hand, there was no relationship between infection and sex, contact with domestic animals, fever, vomiting, nausea, flatulence, anorexia, duration of dialysis and underlying disorders in the two groups. Also, there was a statistically significant difference between age and infection in hemodialysis patients (p=0.003). A higher infection rate was observed in patients under 20 years of age.

Conclusion: Risk factors for Cryptosporidium infection must be controlled. We strongly recommended that stool samples from such patients, especially those with severe or prolonged diarrhea, should be examined with modified Ziehl-Neelsen staining for appropriate and timely treatment.

Angiotensin-converting enzyme inhibitors (ACEIs) are commonly used to treat hypertension. Although generally well tolerated, the adverse effects of ACEIs include hypotension, cough, acute kidney injury and hyperkalemia. Rare reports of ACEI-induced hepatotoxicity have been described, most notably a cholestatic pattern of injury related to captopril.

A 67-year-old male presented to the emergency department with a three-week history of jaundice, pruritis and weakness. Eight weeks before, he began taking ramipril and clopidogrel. His past medical history was significant for previous acute cholestatic liver injury approximately 20 years earlier, which was attributed to methimazole. Abnormal blood work demonstrated aspartate aminotransferase (AST) 47 U/L, alanine aminotransferase (ALT) 46 U/L, total bilirubin 230 µmol/L, direct bilirubin 176 µmol/L, and alkaline phosphatase (ALP) 470 U/L. Abdominal ultrasound and magnetic resonance cholangiopancreatography showed no bile duct obstruction. Further work-up was negative for infectious, autoimmune, or other causes. Percutaneous liver biopsy showed marked cholestasis. With discontinuation of ramipril, the patient demonstrated prolonged cholestasis with partial biochemical improvement and was discharged after six weeks in hospital.

This case represents the first described cross reactivity between ramipril and methimazole, illustrating the complex and poorly understood nature of DILI. Despite the relatively few instances of ACEI-induced liver hepatotoxicity, consideration should be given to discontinuation of ramipril in situations of unknown liver damage. 

Elevated liver enzymes accompanied by Infectious Mononucleosis syndrome are widely seen in primary Epstein-Barr virus infection while acute symptomatic hepatitis without typical presentations of EBV is extremely rare. In the following report, we present a patient with acute isolated hepatitis due to laboratory confirmed Epstein-Barr virus

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