Review Article

Giardia lamblia infection: review of current diagnostic strategies

Hossein Hooshyar, Parvin Rostamkhani, Mohsen Arbabi, Mahdi Delavari

Gastroenterology and Hepatology from Bed to Bench, Vol. 12 No. 1 (2019), 29 January 2019, Page 3-12

Giardiasis has a global distribution and is a common cause of diarrhea in both children and adults and is transmitted via the fecal-oral route through direct or indirect ingestion of cysts.  The laboratory diagnosis of Giardia mainly based on demonstration of microscopic cyst or  trophozoite in stool samples but several immunological-based assays and molecular methods also are available for giardiasis diagnosis. The aim of this study was to conduct a review of the methods applied in medical laboratory and highlights pitfalls and challenges of them for diagnosis of giardiasis. In this article we evaluated the giardia diagnostic methods with a broad review of literature, electronic databases and books. The search covered the articles and some textbook published up to 2018.

  It concludes that traditional microscopy combination with stool concentration method should still be held in the routine medical laboratory due to economical and high sensitivity and immunological-based assay and molecular methods are recommended used as a complementary test to the traditional technique

Original Article

Restless leg syndrome a common undiagnosed comorbidity of clinical significance in cirrhosis

Akash Rajender, Saumya Mathur, Priyanka Choudhary, Shalini Upadhyay, Gaurav R, Rajat Bhargava, Subhash Nepalia

Gastroenterology and Hepatology from Bed to Bench, Vol. 12 No. 1 (2019), 29 January 2019, Page 13-16


Background & Aim: Sleep disturbances are common in cirrhosis. Restless leg syndrome is a chronic sensorimotor sleep disorder with an irresistible urge to move limbs. Our aim was to study prevalence &association of RLS in liver cirrhosis subjects.

Material & Method: Two hundred consecutive cirrhosis patients, presenting at Mahatma Gandhi Medical College & Hospital, Jaipur were evaluated. 157 subjects meeting the inclusion criteria were selected for further evaluation. Revised International Restless Legs Syndrome Study Group (IRLSSG) criteria 2012, was used for diagnosed of RLS. Severity of RLS was evaluated by a validated Hindi translation of International RLS severity (IRLS) scoring system.

Result: Of studied 157 cirrhotic, the mean age was 46.4 ± 10 years, 109 (69.43%) males and 48 (30.57%) females. 41 (26.11%) cirrhotic subjects had Restless Leg Syndrome (RLS). Child Turcotte Pugh (CTP) Class (A 9/55, B 15/68, C 17/34; p 0.043) and alcohol as etiology for liver dysfunction (p 0.03) was significantly associated with RLS.

Conclusion: RLS is common comorbidity in cirrhosis, especially in alcohol related cirrhosis. RLS has a clinical correlation with prognosis & severity of cirrhosis.

The effect of nutritional education and continuous monitoring on clinical symptoms, knowledge, and quality of life in patients with cirrhosis

Pezhman Alavinejad, Eskandar Hajiani, Baharak Danyaee, Mehrnaz Morvaridi

Gastroenterology and Hepatology from Bed to Bench, Vol. 12 No. 1 (2019), 29 January 2019, Page 17-24

Aim: In this study, we aimed to evaluate the effectiveness of an educational intervention in patients with liver cirrhosis.

Background: Liver cirrhosis is end stage of liver diseases with many complications that affect quality of life and nutritional status in cirrhotic patients. Today, educational intervention and nutritional counseling is a key factor for preventing disease process and improving quality of life in patients with chronic diseases.

Methods: This quasi-experimental, non-randomized, pre and post intervention was conducted as a pilot study on cirrhotic patients. Educational intervention and nutritional counseling was performed in clinical visits and via guide booklet. Chronic liver disease questionnaire (CLDQ) and knowledge questionnaire were used to assess patients' quality of life and knowledge. Blood samples were taken before and after intervention for assessment of laboratory outcomes.

Results: One hundred and seven patients referred to Research Center for enrolling in the trial. Twenty-eight did not meet inclusion criteria and seven patients were excluded from the study for lack of proper follow-up. Final analyses were done on 72 patients. Quality of life and knowledge of cirrhotic patients improved significantly after educational intervention (P < 0.0001). Biochemical characteristics were not changed significantly. Ascites and edema were improved significantly (P = 0.005 and P = 0.002, respectively). There was significant difference before and after intervention in the days of hospitalization (P = 0.001).

Conclusion: We concluded a simple educational intervention and continuous monitoring for 6 months can affect clinical outcomes, quality of life, hospital admissions days, and knowledge of patients with cirrhosis.

Early postoperative oral feeding shortens first time of bowel evacuation and prevents long term hospital stay in patients undergoing elective small intestine anastomosis

Behzad Nematihonar, Akram Yazdani, Rofeideh Falahinejadghajari, Alireza Mirkheshti

Gastroenterology and Hepatology from Bed to Bench, Vol. 12 No. 1 (2019), 29 January 2019, Page 25-30

Background We compared the outcome of early oral feeding (EOF) compared to traditional oral feeding (TOF) in patients undergoing elective small intestine anastomosis.

Materials and Methods This randomized single-blinded controlled trial was performed on 108 patients who underwent small intestine anastomosis. The patients were randomly assigned to schedule EOF (with starting oral feeding on the first day after surgery and complete return of the Gag reflex) or TOF (with delaying oral feeding till the first passage of flatus and bowel movement). We compared the overall prevalence of postoperative complication, length of hospital stays and outcome of surgery in two groups.

Results The time to first passage of stool was shorter in EOF group than in TOF group (3.2 ± 0.59 days versus 3.6 ± 0.66 days (p = 0.006). The mean length of hospital stay in EOF group was also shorter than in TOF group (3.8 ± 1.06 days versus 6.3 ± 1.0 days, p = 0.001). The length of hospital stays shorter than 4 days was found in 75.9% of patients in EOF group and 11.1% of those patients in TOF group (p < 0.001).

Conclusion The use of EOF in patients undergoing small intestine anastomosis can shorten time to first passage of stool as well as reduce the length of hospital stay.  

Prevalence of helicobacter pylori infection in Sari northern Iran; A population based study

Iradj Maleki, Masoumeh Mohammadpour, Niloufar Zarrinpour, Mohadeseh Khabazi, Reza Ali Mohammadpour

Gastroenterology and Hepatology from Bed to Bench, Vol. 12 No. 1 (2019), 29 January 2019, Page 31-37

Aim: In this study prevalence rate of Helicobacter pylori and its associated factors have been investigated in urban and rural areas of Sari.

Background: Helicobacter pylori has an important role in gastrointestinal diseases including peptic ulcer and gastric cancer. It is the most common infection in human population worldwide. Hence, the epidemiology of this infection in all parts of the world is of utmost importance.

Methods: We conducted a cross-sectional study on 497 individuals ranging 15-65 years of age in Sari city and its surrounding rural residents. The sampling method was a cluster random sampling multi staged in stratified population by urban and rural areas. Questionnaires for personal and socio-economic data were filled. Blood samples were drawn and kept for analysis (IgG antibody ELISA for Helicobacter pylori). The data was analyzed by SPSS statistical software and Chi-square test and logistic regression were used.

Results: The prevalence of helicobacter infection was 44.5% in the studied population. This prevalence was 41.3% and 47.8% in urban and rural areas, respectively. Just a significant association between the infection and the age of subjects was observed in multiple regression analysis (p=0.001). However, in univariate analysis the level of education was also significantly associated with Helicobacter pylori infection (p=0.015). No other variable was associated with the infection.

Conclusion: The prevalence of helicobacter infection has dropped significantly in the region in comparison with the previous studies during the last 15 years.

Keywords: Helicobacter pylori, Prevalence study, Epidemiology, Iran.

(Please cite as: Maleki I, Mohammadpour M, Zarrinpour N, Khabazi M, Mohammadpour RA. Prevalence of Helicobacter pylori infection in Sari Northern Iran; a population based study. Gastroenterol Hepatol Bed Bench 2019;12(1):31-37).

Comparison of ISG15, IL28B and USP18 mRNA levels in peripheral blood mononuclear cells of chronic hepatitis B virus infected patients and healthy individuals

Seyed Mohammad Ali Hashemi, Jamal Sarvari, Mohammad Reza Fattahi, Razieh Dowran, Amin Ramezani, Seyed Younes Hoseini

Gastroenterology and Hepatology from Bed to Bench, Vol. 12 No. 1 (2019), 29 January 2019, Page 38-45

Background: Despite the presence of an efficient vaccine for hepatitis B virus (HBV), it remains a public health challenge, worldwide. The effort to uncovering immune genes attributed to infection outcome is in undergone. The purpose of this study was to evaluate the expression level of Interferon-stimulated Gene 15 (ISG15), Interleukin28B (IL28B) and Ubiquitin specific peptidase 18 (USP18) genes in Peripheral Blood Mononuclear Cells (PBMCs) of patients with chronic active and inactive hepatitis B in comparison with healthy control individuals.

Materials and Methods: This Cross-sectional study was conducted on hepatitis B infected patients that were admitted to Clinic of Liver diseases, Shiraz, between January 2016-2017. Gene expression assay was performed on PBMCs of blood samples by the help of Real-time PCR method. The relative expression of each gene was calculated regarding 2-?Ct formula.

Results: Interleukin 28B gene expression showed no statistically significant difference between three studied groups. The expression level of ISG15 gene was significantly higher in the healthy control group compared to active (P= 0.0068) and inactive chronic subjects(P<0.0001). Similarly, USP18 expression level in the control group was also significantly higher compared to the active (P= 0.0228) and inactive chronic patients (P=0. 0226).

Conclusion: The results of this study showed that the expression level of ISG15 and USP18 but not IL28B were higher in healthy individuals than those infected with HBV. This difference expression may highlight the role of ISG15 and USP18 in immune-related mechanism HBV infection.

A gene variation of interferon gamma receptor-I promoter (rs1327474A>G) and chronic hepatitis C virus infection

Maryam Karkhane, Seyed Reza Mohebbi, Afsaneh Sharifian, Amir Ghaemi, Hamid Asadzadeh Aghdaei, Mohammad Reza Zali

Gastroenterology and Hepatology from Bed to Bench, Vol. 12 No. 1 (2019), 29 January 2019, Page 46-51

Interferon gamma signaling pathway is an important trigger for activating antiviral immune responses and production of wide variety of molecules with anti-microbial profiles including type 1 cytokines. Any defect or variation in IFNG signaling pathway may result in susceptibility or progression to diverse diseases such as inflammatory and virus associated disorders. Rs1327474 A/G also known as -611 A/G is an important variation which is located in promoter region of IFNGR1 and may have potent risk for HCV susceptibility. In present survey, we attempted to inquire the plausible linkage of rs1327474 A/G and HCV chronic infection or the clearance of the virus. For this purpose, 154 HCV patients and 200 normal controls were enrolled in the study, and genomic DNA was isolated from PBMCS and IFNGR1 -611 polymorphism was genotyped by polymerase chain reaction- Fragments Length Polymorphism (PCR-RFLP) method. While, AA, AG and GG genotype frequency included 37.8%, 53.7%, 8.5% in healthy controls, 41.6%, 46.1%, 12.3% were found in chronic HCV patients. Interestingly, allelic percentage was similar in both separated groups within 64.7%, 35.3% and 65.3%, 34.7% were obtained for T and G allele in control and case group respectively. Despite of our exception for the possible role of this variation in an important promoter region of IFGR1 gene, rs1327474 A/G was not associateed with HCV chronic infection among an Iranian studied group. Comprehensively, -611A/G cannot consider as a risk biomarker for susceptibility to chronic HCV disease.

Determination of virulence determinants of Escherichia coli strains isolated from patients with colorectal cancer compared to the healthy subjects

Omid Zarei, Mohammad Reza Arabestani, Amir Majlesi, Younes Mohammadi, Mohammad Yousef Alikhani

Gastroenterology and Hepatology from Bed to Bench, Vol. 12 No. 1 (2019), 29 January 2019, Page 52-59

Background: Colon cancer is one of the most important malignancies in recent years. Escherichia coli (E.coli) is the most important infectious agents associated with colon cancer that has numerous virulence factors such as iron uptake and adhesion factors involved in the process of inflammation and colorectal cancer. Several virulence factors such as iron and adhesion factors can contribute to the disease caused by E. coli.

Material and Method: Of the three normal, inflammatory bowel disease (IBD), colorectal cancer (CRC) groups, 40 E. coli strains isolated after confirmation by biochemical and molecular methods. After determining the phylogroup, the frequency of virulence factors was measured by a PCR method. Biofilm test was also performed on phenotypes on all three groups.

Result: In the determination of the phylogroup associated with the bacteria, the CRC had a maximum incidence of phylogroups B2 and A. In the analysis of fimH, papA, papC, iutA, ireA and fyuA the highest frequency of these genes was observed in these two phylogroups. Statistical analyzes were only significant for the ireA gene. There was also no significant difference in Biofilm productions in E. coli strains among the three groups.

Conclusion: Contrary to previous studies that focused solely on E. coli toxins, we found that factors such as iron uptake and adhesion can also be effective in developing IBD and colorectal cancer. Also found that the formation of biofilm is a special feature of E. coli isolated from the colon.

Gene expression profile analysis of colon cancer grade II into grade III transition by using system biology

Mohammad Rostami-Nejad, Sina Rezaei Tavirani, Vahid mansouri, Somayeh Jahani-Sherafat, Hamideh Moravvej Farshi

Gastroenterology and Hepatology from Bed to Bench, Vol. 12 No. 1 (2019), 29 January 2019, Page 60-66

Aim: Gene expression profile analysis of colon cancer grade II into grade III transition by using system biology.

Background: Colon cancer is one of lethal cancer in men and women. Treatment in advanced colon cancer is difficult and survival rate is low.

Methods: Gene expression profiles of children patients with non-preforated appendicitis in comparison with the samples with non- appendicitis abdominal pain are analysis via protein – protein interaction PPI and the critical compounds are introduced by STITCH.

Results: Six critical genes including MAPK3, AKT1, SRC, TP53, GAPDH, and ALB were identified as a possible biomarker panel related to colon cancer grade II to III transition. Among these critical genes roles of MAPK3, AKT1, SRC, TP53 are highlighted.

Conclusion: It was concluded that target therapy to regulate SRC and TP53 may be the effective therapeutic way to treatment of colon cancer and more researches in necessary to design drugs for these purposes.

Keywords: Colon cancer, gene, biomarker.

(Please cite as: Rostami-Nejad M, Rezaei Tavirani S, Mansouri V, Jahani-Sherafat S, Moravvej Farshi H. Gene expression profile analysis of colon cancer grade II into grade III transition by using system biology. Gastroenterol Hepatol Bed Bench 2019;12(1):60-66).

Investigation of health benefits of cocoa in human colorectal cancer cell line, HT-29 through interactome analysis

Mona Zamanian Azodi, Mostafa Rezaei-Tavirani

Gastroenterology and Hepatology from Bed to Bench, Vol. 12 No. 1 (2019), 29 January 2019, Page 67-73

Aim: This bioinformatics study aims to identify the potential key genes influenced by cocoa extraction treatment on colon cancer cell line HT-29 after 24h.

Background: Cocoa consumption has been claimed to have a beneficial effect on cancer.

Methods: The microarray dataset (GSE94154) from GEO, was the source for differentially expressed genes (DEGs) extraction through GEO2R analysis. The comparison was between 3 controls of colorectal cell line HT-29 and 3 ones incubated with cocoa extraction after 24 h. Afterwards, the top significant DEGs were assigned for protein-protein interaction network construction and analysis by Cytoscape v 3.7.0. and the related applications.

Results: The findings indicate that there are 222 up-regulated and 28 down-regulated genes among 250 top-ranked DEGs. What is more, centrality analysis of the DEGs network identified 10 hub-bottlenecks that ISG15, MX 1, and STAT1 were among the significant differential expression genes with the contribution in type 1 interferon signaling pathway, positive regulation of erythrocyte differentiation, and negative regulation of viral genome replication.

Conclusion:  In conclusion, the underlying mechanisms of cocoa treatment could be clarified by its up-regulatory and modulatory effect on prominent genes of tumor suppressor family. In other words, valuable clues for future clinical studies of cocoa health benefits are highlighted in this study once validation studies are carried out. 

Case Report

An unusual cause of chronic diarrhea: plastron appendiciti

Bilal Katipoglu, Gokhan Yirgin, Burak Furkan Demir, Ihsan Ates

Gastroenterology and Hepatology from Bed to Bench, Vol. 12 No. 1 (2019), 29 January 2019, Page 74-75

Chronic diarrhea is defined as diarrhea that lasts longer than four weeks. Etiology of chronic diarrhea includes inflammatory bowel disease, malabsorption syndromes, irritable bowel disease, chronic parasitic infections, bacterial toxins, drugs and motility disorders. Plastron appendicitis is an abscess formation that occurs when the appendix is surrounded by the omentum following perforation of acute appendicitis. The cases usually present with abdominal pain, nausea, vomiting, and abdominal mass. Chronic diarrhea is a rare finding. In this case report, we present a case of a 63-year-old man who had diarrhea and intermittent abdominal pain for 3 months and underwent a diagnosis of plastron appendicitis as a result of the investigations.

Primary biliary cholangitis , previously known as primary biliary cirrhosis (PBC), is the most common autoimmune diseases of the liver (ALD). Patients with PBC may present with typical biliary pattern symptoms. Also the presence of anti mitochondrial autoantibodies (AMAs) is the laboratory hallmark of PBC, which molecular target antigens are members of 2-oxoacid dehydrogenase complex of enzymes.

In recent years, autoantibodies (Aab) targeting subcellular structures described as the rods and rings (R&R) pattern in HEp-2 ANA have been presented as a unique and particular case of Aab generation. These R&R structures are composed of inosine monophosphate dehydrogenase type 2 (IMPDH2), and their formation can be induced in vitro by several small-molecule inhibitors.

Aab targeting these relatively unknown structures have been almost exclusively observed in hepatitis C virus (HCV) patients who have undergone treatment with pegylated interferon-a/ribavirin (IFN/RBV) therapy. Literature showed that anti-RR Aab have not been found in treatment-naïve HCV patients or in patients from any other disease.

Now We present and characterized a case patient with contemporary presence of AMAs and R&R Aab in PBC, without any laboratory evidences of HCV and/or other hepatic virus infection.

For our knowledge this is the first case described in the Literature.

R&R Aab in patients without any clinical/laboratory signs or symptoms of Hepatitis virus and without pharmacological therapy open the window to the alternative scenario: the association of these Aab to ALD. The AMA-negative cases are an intriguing diagnostic problem. Our work demonstrated that R&R Aab can be present in PBC case.  The interesting idea suggesting suggested that R&R Aab may be present also in AMA-negative PBC and they can considered a new diagnostic tool in this specific clinical condition.

Other study and cases are needed but the presence of R&R Aab linked with AMAs and PBC may be explained by alterations in immune regulation caused by autoimmunity in a particular genetic background.

Clinical Quiz