Description: Spontaneous sublingual hematoma and intramural small bowel hematoma are rare and serious complications of anticoagulant therapy. Though previously reported individually, there has been no previous report of the same two complications occurring in a single patient. A 71-year-old Caucasian man, who was on warfarin for atrial fibrillation, presented with difficulty in swallowing due to a sublingual hematoma. He was observed in our intensive care unit, his warfarin was held and he recovered with conservative management. He represented two months later with a two day history of abdominal pain and distension. An abdominopelvic computed tomography (CT) scan now showed small bowel obstruction due to intramural small bowel hematoma and haemorrhagic ascites. Again, this was treated expectantly with a good outcome. In conclusion, life threatening haemorrhagic complications of oral anticoagulant therapy can recur. Conservative treatment is successful in most cases, but an accurate diagnosis is mandatory to avoid unnecessary surgery. CT scan is the investigation of choice for the diagnosis of suspected haemorrhagic complications of over coagulation.

Description: Irritable bowel syndrome (IBS), a chronic disorder, greatly impacts the lives of those affected. Approximately one quarter of the North American population suffers from this condition that includes abdominal pain, discomfort and alterations in normal bowel function. Constipation-subtype IBS (IBS-C) is often found to be a prevalent subtype; however, a lack of knowledge and effective treatment options remains surrounding this disorder. In the course of an ongoing study conducted by our research team on the use of acupuncture and moxibustion in the management of IBS symptoms, a considerable number of screened patients have met the widely accepted Rome III criteria for IBS-C.

Description: Isolated dilation of common bile duct (CBD) with normal sized pancreatic duct and without identifiable stones or mass lesion (unexplained) is frequently encountered by computed tomography/magnetic resonance imaging. We studied the final diagnoses in these patients and tried to elucidate factors that can predict a malignant etiology. This is a retrospective analysis of prospective database from a University based clinical practice (2002- 2008). We included 107 consecutive patients who underwent endoscopic ultrasound (EUS) for evaluation of isolated and unexplained CBD dilation noted on contrast computed tomography scans. EUS examination was performed using a radial echoendoscope followed by a linear echoechoendoscope, if a focal mass lesion was identified. Fine-needle aspirates were assessed immediately by an attending cytopathologist. Main outcome measurements included i) prevalence of neoplasms, CBD stones and chronic pancreatitis and ii) performance characteristics of EUS/EUS-fine needle aspiration (EUS-FNA). A malignant neoplasm was found in 16 patients (14.9%) of the study subjects, all with obstructive jaundice (ObJ). Six patients had CBD stones; three with ObJ and three with abnormal liver function tests. EUS findings suggestive of chronic pancreatitis were identified in 27 patients. EUSFNA had 97.3% accuracy (94.1% in subset with ObJ) with a sensitivity of 81.2% and specificity of 100% for diagnosing malignancy. Presence of ObJ and older patient age were only significant predictors of malignancy in our cohort. Amongst patients with isolated and unexplained dilation of CBD, the risk of malignancy is significantly higher in older patients presenting with ObJ. EUS-FNA can diagnose malignancy in these patients with high accuracy besides identifying other potential etiologies including missed CBD stones and chronic pancreatitis.

Description: Small bowel obstruction is a known complication of Crohn’s disease. Determining need for operation is a demanding task. The aim of this study was to fine tune the decision-making process by evaluating standard clinical and laboratory parameters in small bowel obstruction of any cause and compare etiologies. Consecutive patients with Crohn’s disease and small bowel obstruction were selected retrospectively and compared to a randomly selected group of non Crohn’s patients with obstruction over a 9 year period. Twenty-two clinical, laboratory and radiological variables were assessed for the following outcomes: i) diagnosis of Crohn’s; ii) operative or non operative treatment in Crohn’s; iii) operative or non operative treatment without Crohn’s; iv) exacerbation or adhesions causing obstruction among Crohn’s patients. Multivariable models were developed for each outcome using logistic regression. Age less than 50, history of smoking, Jewish ethnicity, white count 〉11x10E9, neutrophils 〉7.5x10E9 and platelet volume 〈9.9 fL, supported the diagnosis of Crohn’s disease. Operation in Crohn’s disease within the same admission was associated with a history of smoking, temperature 〉38˚, high pulse 〉100, leukocytosis (〉11x10E9) and obstruction on abdominal scan, while operation in patients without Crohn’s in the sentinel admission, was associated with temperature 〉38˚, tachycardia, leukocytosis (〉11x10E9) and previous operation. Confirmation of these predictive patterns in a validation group could help in clinical decisions regarding therapeutic options in an emergency setting.

Description: Although Helicobacter pylori ( H. pylori ) infection has been known to be associated with several upper gastrointestinal disorders such as peptic ulcer and gastric cancer, the relationship between H. pylori infection and dyspeptic symptoms remains controversial. Furthermore, it is still not clear which factors are associated with H. pylori infection in the Iranian population. We investigated the prevalence of H. pylori infection in dyspeptic patients and factors associated with H. pylori infection in the Iranian population. In this cross-sectional study, 303 patients with dyspeptic symptoms underwent endoscopy. Clinical data and a questionnaire about gastrointestinal symptoms were collected from each patient. H. pylori status was evaluated by histological examination. Among the 303 patients, 263 (86.8%) were found to be positive for H. pylori. The prevalence of H. pylori infection decreased significantly with age. There was no difference in the prevalence of H. pylori infection between the patients with and those without a family history of gastroduodenal diseases. Among 250 patients with abdominal pain, 219 (87.6%) were infected with H. pylori. Among 211 patients with epigastric abdominal pain, 185 (87.7%) were infected with H. pylori . It was observed that belching was significantly associated with H. pylori infection (P = 0.03). Dyspepsia triggered by the consumption of tea was higher in H. pylori- positive patients than in H. pylori- negative patients (P = 0.03). The prevalence of H. pylori infection in dyspeptic patients was quite high in Iran. Belching and dyspepsia triggered by tea consumption was related with H. pylori infection.

Description: We report a case of a 48-year-old female, who presented with refractory haemetemesis. Her oesophago-gastroduodenoscopy showed only a healing ulcer but profuse bleeding was seen from duodenum. In spite of a negative oesophago-gastroduodenoscopy she was bleeding profusely with haemodynamic decompensation. Doppler coeliac trunk showed a suprapancreatic cystic lesion with yin-yang pattern of blood flow confirming a pseudo aneurysm involving the superior and inferior pancreatioduodenal arterial arcade using digital subtraction angiography. The conversion of a pancreatic pseudo cyst into a pseudo aneurysm is a potential lethal complication because, when rupture occurs, mortality rises up to 40%.She was diagnosed to have pancreatic pseudocyst, psedoaneurysm and haemosuccus pancreaticus with wirsungorrhagia and was offered arterial embolization following which she improved. Patients with chronic calcificpancratitis (CCP) could remain silent and can present with normal amylase and lipase. Complications such as pseudocysts or pseudoaneurysms can be asymptomatic. The pancreas should be considered a possible site of hemorrhage in CCP in cases of refractory upper gasrtrointestinal haemorrhage. We highlight the importance of looking for causes other than bleeding duodenal/gastic ulcer/oesophageal varices in case of a refractory hametemeis giving the patient option of a nonsurgical modality of treatment and it’s reduced risks.The effectiveness of embolistion for bleeding psuedoaneurysms is emphasized.

Description: Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction. This entity has been reported as either primary idiopathic or secondary to other diseases. We report SEP in 2 cirrhotic patients and review the literature. Both patients had decompensated cirrhosis and episodes of spontaneous bacterial peritonitis. One patient underwent a Denver shunt placement before developing SEP. This patient remains alive and is managed conservatively. The other patient deceased from multi-organ failure after the resection of gangrened small bowel. The manifestations of SEP are often nonspecific that leads to misdiagnosis and/or delayed diagnosis. Early diagnosis of SEP is difficult but not impossible. Surgical treatment is often required when intestinal obstruction is present. Nevertheless, patients with this problem can be treated conservatively with immunosuppressive therapy with or without total parenteral nutrition (TPN) before going for surgery.

Description: Endoscopic submucosal dissection (ESD) is a minimally invasive technique developed by Japanese endoscopists that allows one-piece endoscopic removal of early malignant lesions in the gastrointestinal tract. There is now a large and ever-increasing number of reports worldwide, and in the West use of this technique is on the increase. New materials and techniques have been developed to improve the technical aspects of ESD. Recent reports show successful clinical outcomes and improved overall 5-year survival rates for this technique. This review aims to offer an update of ESD based on the latest reports in the literature.

Description: Spontaneous bacterial peritonitis (SBP) is a frequent and sever complication of cirrhotic patients with ascites. The aim of this study was to assess diagnostic value of leukocyte esterase reagent strip test (Medi-Test Combi) for the rapid diagnosis of SBP in cirrhotic patients with ascites in the University Hospital of Imam Reza in Tabriz, Iran. In this study, 132 consecutive samples from cirrhotic patients who underwent abdominal paracentesis were evaluated. These samples were tested by 3 methods: i) manual cell count with differential study, SBP was defined as having poly-morphonuclear cells count of ≥250/mm3; ii) culture of ascetic fluid samples; iii) all samples were tested by leukocyte esterase dipsticks. The sensitivity, specificity, positive and negative predictive values of two different colorimetric cut-off scales (1+ and 2+) were calculated and compared. The sensitivity, specificity, positive and negative predictive values of 1+ and 2+ cut-off scales to diagnose SBP were 97.5%, 84.6%, 74% and 98.7% for the 1+ cut-off scale and 87.8%, 96.7%, 92.3% and 94.6% for the 2+ cut-off scale. Leukocyte esterase reagent strip test can be used as a rapid test for screening of SBP. The higher cut-off colorimetric scale has a better specificity and positive predictive value but a lower sensitivity.

Description: Oral corticosteroids (CS) have been widely used for treatment of ulcerative colitis (UC) at the price of systemic side effects. Role of topically active oral beclomethasone dipropionate (BDP) in clinical practice is still unclear. The aim of this paper is to investigate efficacy and tolerability of a high dose BDP regimen in mild to moderately active UC. Twenty-five patients (9 males, aged 25-40 years) with mild to moderately active UC, unresponsive to oral and topical 5-ASA (4.8 gr daily) and BDP (5 mg daily), were enrolled. All patients continued 5-ASA plus high dose oral BDP (15 mg od for 4 weeks and than tapered). Clinical, endoscopic, histological and laboratory parameters were monitored. Mean disease activity index (DAI) score at study entry was 8.82±4. Response to treatment was observed in all patients after 2 weeks. Remission was observed in all patients within 4-6 weeks from entering the study (mean DAI score: 2.34±0.5) and maintained throughout 6-month follow-up. No major adverse events were documented. Quality of life global evaluation score improved. This study provides the first evidence of efficacy and safety of high dose oral BDP-scheme in UC demonstrating excellent tolerability and favourable acceptability profile. This new BDPscheme might be a valid alternative to conventional oral CS when standard dose BDP is not effective. Future studies are needed to explore further clinical indications.