Application of artificial intelligence in pancreas endoscopic ultrasound imaging- A systematic review

The pancreas is a vital organ in digestive system which has significant health implications. It is imperative to evaluate and identify malignant pancreatic lesions promptly in light of the high mortality rate linked to such malignancies. Endoscopic Ultrasound (EUS) is a non-invasive precise technique to detect pancreas disorders, but it is highly operator dependent. Artificial intelligence (AI), including traditional machine learning (ML) and deep learning (DL) techniques can play a pivotal role to enhancing the performance of EUS regardless of operator. AI performs a critical function in the detection, classification, and segmentation of medical images. The utilization of AI-assisted systems has improved the accuracy and productivity of pancreatic analysis, including the detection of diverse pancreatic disorders (e.g., pancreatitis, masses, and cysts) as well as landmarks and parenchyma. This systematic review examines the rapidly developing domain of AI-assisted system in EUS of the pancreas. Its objective is to present a thorough study of the present research status and developments in this area. This paper explores the significant challenges of AI-assisted system in pancreas EUS imaging, highlights the potential of AI techniques in addressing these challenges, and suggests the scope for future research in domain of AI-assisted EUS systems.

Management of Malignant Gastric Outlet Obstruction: A Comprehensive Review on the Old, the Classic and the Innovative Approaches

Gastrojejunostomy is the principal method of palliation for unresectable malignant gastric outlet obstructions (GOO). Gastrojejunostomy was traditionally performed as a surgical procedure with an open approach butrecently, notable progress in the development of minimally invasive procedures such as laparoscopic gastrojejunostomies have emerged. Additionally, advancements in endoscopic techniques, including endoscopic stenting (ES) and endoscopic ultrasound-guided gastroenterostomy (EUS-GE), are becoming more prominent. ES involves the placement of self-expandable metal stents (SEMS) to restore luminal patency. ES is commonly the first choice for patients deemed unfit for surgery or at high surgical risk. However, although ES leads to rapid improvement of symptoms, it carries limitations like higher stent dysfunction rates and the need for frequent re-interventions. Recently, EUS-GE has emerged as a potential alternative, combining the minimally invasive nature of the endoscopic approach with the long-lasting effects of a gastrojejunostomy. Having reviewed the advantages and disadvantages of these different techniques, this article aims to provide a comprehensive review regarding the management of unresectable malignant GOO.

Rare single-nucleotide variants of MLH1 and MSH2 genes in patients with Lynch syndrome

BACKGROUND

Approximately 5% of colorectal cancers (CRCs) are hereditary. Lynch syndrome (LS), also known as hereditary nonpolyposis colorectal cancer (HNPCC), is the most common form of recognized hereditary CRC. Although Iran, as a developing country, has a high incidence of CRC, the spectrum of variants has yet to be thoroughly investigated.

AIMS

This study aimed to investigate pathogenic and non-pathogenic variants in MLH1 and MSH2 genes in Iranian patients with suspected Lynch syndrome (sLS).

METHODS AND RESULTS

In the present study, 25 peripheral blood samples were collected from patients with sLS and high microsatellite instability (MSI-H). After DNA extraction, all samples underwent polymerase chain reaction and Sanger sequencing to identify the variants in the exons of MLH1 and MSH2 genes. The identified variants were interpreted using prediction tools, and were finally reported under ACMG guidelines. In our study population, 13 variants were found in the MLH1 gene and 8 in the MSH2 gene. Interestingly, 7 of the 13 MLH1 variants and 3 of the 8 MSH2 variants were novel, whereas the remaining variants were previously reported or available in databases. In addition, some patients with sLS did not have variants in the exons of the MLH1 and MSH2 genes. The variants detected in the MLH1 and MSH2 genes had specific characteristics regarding the number, area of occurrence, and their relationship with demographic and clinicopathologic features.

CONCLUSION

Overall, our results suggest that analysis of MLH1 and MSH2 genes alone is insufficient in the Iranian population, and more comprehensive tests are recommended for detecting LS.

Comparison of the efficacy of diltiazem versus fluoxetine in the treatment of distal esophageal spasm: A randomized-controlled-trial

BACKGROUND AND STUDY AIM

Distal esophageal spasm is an uncommon esophageal motility disorder presenting with non-cardiac chest pain and dysphagia. The main goal of therapy is symptom relief with pharmacologic, endoscopic, and surgical therapies. Pharmacologic treatment is less invasive and is the preferred method of choice. The purpose of this study was to compare the effectiveness of diltiazem versus fluoxetine in the treatment of distal esophageal spasm.

PATIENTS AND METHODS

A total of 125 patients with distal esophageal spasm diagnosed using endoscopy, barium esophagogram, and manometry were evaluated. Patients were divided into diltiazem and fluoxetine groups and received a 2-month trial of diltiazem + omeprazole or fluoxetine + omeprazole, respectively. Of 125 patients, 55 were lost to follow up and 70 were eligible for final analysis. Clinical signs and symptoms were assessed before and after therapy using four validated questionnaires: Eckardt score, short form-36, heartburn score, and the hospital anxiety and depression scale.

RESULTS

Both regimens significantly relieved symptoms (a decrease in mean Eckardt score of 2.57 and 3.18 for diltiazem and fluoxetine groups, respectively; and a decrease in mean heartburn score by 0.89 and 1.03 for diltiazem and fluoxetine groups, respectively). Patients' quality of life improved based on short form-36 (an increase in mean score of 2.37 and 3.95 for fluoxetine and diltiazem groups, respectively). There was no relationship between patients' improvement and severity of symptoms. Psychological findings based on the hospital anxiety and depression scale were inconsistent (a decrease in mean of 0.143 and 0.57 for fluoxetine and diltiazem groups, respectively; p > 0.05).

CONCLUSION

Fluoxetine and diltiazem were effective for clinical symptom relief in patients with distal esophageal spasm, but were not promising for improving psychological symptoms. Neither regimen was superior in terms of efficacy. Consequently, it is key to consider side effects and comorbidities when choosing a therapy.

Whole exome sequencing identifies MAP3K1, MSH2, and MLH1 as potential cancer-predisposing genes in familial early-onset colorectal cancer

The incidence of early-onset colorectal cancer (CRC), which affects people under 50, is increasing for unknown reasons. Additionally, no underlying genetic cause is found in 20%-30% of patients suspected of having familial CRC syndrome. Whole exome sequencing (WES) has generated evidence for new genes associated with CRC susceptibility, but many patients remain undiagnosed. This study applied WES in five early-onset CRC patients from three unrelated families to identify novel genetic variants that could be linked to rapid disease development. Furthermore, the candidate variants were validated using Sanger sequencing. Two heterozygote variations, c.1077-2A>G and c.199G>A, were found in the MSH2 and the MLH1 genes, respectively. Sanger sequencing analysis confirmed that these (likely) pathogenic mutations segregated in all the affected families' members. In addition, we identified a rare heterozygote variant (c.175C>T) with suspected pathogenic potential in the MAP3K1 gene; formally the variant is of uncertain significance (VUS). Our findings support the hypothesis that CRC onset may be oligogenic and molecularly heterogeneous. Larger and more robust studies are needed to understand the genetic basis of early-onset CRC development, combined with novel functional analyses and omics approaches.

An update of the variant spectrum of the APC gene in Iranian familial adenomatous polyposis patients

Familial adenomatous polyposis (FAP) is an autosomal dominant colorectal cancer syndrome that is characterized by the development of multiple adenomas in the colon and rectum with high penetrance rates. This disease has specific features like the occurrence of pathogenic variations in the APC gene and diverse FAP phenotypes due to the occurrence region. In this study we aimed to evaluate pathogenic variants in exons of the APC gene in Iranian patients with FAP. A total of 35 FAP individuals were referred to the gastroenterology ward of Taleghani Hospital. As the aim of the study was to study the germline variations in the participants, the peripheral blood was collected and after the DNA extraction, PCR, and Sanger sequencing processes for the APC gene, the results were evaluated by the ACMG classification guidelines to report their pathogenicity. Accordingly, out of eight specific detected variants, three of them were novel, and the rest were reported previously. These eight variants were all truncating protein and pathogenic, and they were limited to 849-1378 codons. Overall, detected variants revealed discrepancies and parallels with previous reported cases in terms of quantity, occurrence region, and association with demographic and clinicopathological characteristics of patients. The spectrum of detected variants and the patient's phenotype showed distinct characteristics, such as occurrence in specific regions and the absence of extracolonic symptoms like Congenital hypertrophy of the retinal pigment epithelium (CHRPE). These findings open the path to comprehending the typical symptoms, their rarity, and their occurrence in the Iranian population and also due to the facts, we found that the studying of the APC gene alone for diagnosing FAP disease is not sufficient, and considering other genes are completely rational in the case of sequencing and studying the variants.

The impact of COVID-19 on national program of colorectal cancer screening in Tehran, Iran: a multicenter study

BACKGROUND

The COVID-19 pandemic has affected all aspects of the healthcare system, including prevention, treatment, rehabilitation of diseases and health education; access to essential therapies; allocation of finance & facilities to health issues, and governance of diseases, including COVID-19 and other diseases. Consequently, the burden of COVID-19 was not only attributable to the multiorgan involvement and detailed presentation of the disease but also to the inadequate management of other diseases resulting from the exclusive allocation of resources and medical personnel to the pandemic crisis. Over the mentioned period, one observed deficiency was the lack of public and official favor for conventional screening protocols. To this end, this study aims to evaluate the impact of the COVID-19 pandemic on colorectal cancer (CRC) screening protocols at Shahid Beheshti University of Medical Sciences in Tehran, Iran, in an effort to identify individuals at risk for CRC and provide them with intensive screening and therapy.

METHODS

This is an observational study comparing the number of candidates for CRC screening referred to primary, secondary, and tertiary health-care centers under supervision of Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran in a 2-year interval before and after COVID-19 pandemics. Patients with intermediate- and high-risk criteria for colorectal cancer were included in the study and were screened by fecal immunochemical test. Patients with positive or indeterminate fecal test results were further evaluated with colonoscopy in research institute for gastroenterology and liver diseases where is a tertiary referral center for CRC screening. Finally, the decrease percentage of screening tests and endoscopic findings during the pandemic period compared to pre-pandemic period was calculated and interpreted.

RESULTS

A significant decrease in the number of performed fecal immunochemical tests (FITs), referred positive FITs, and referred patients with positive alarm signs to the Research Institute of Gastroenterology and Liver Diseases (RIGLD) center inevitably led to a considerable decrease in the number of endoscopic findings, including high-risk adenomas, sessile serrated polyps, and even early-stage colorectal cancers (CRCs).

CONCLUSION

The disruption of screening protocols caused by the COVID-19 pandemic appears to increase the number of patients with high-grade and end-stage CRCs referred in the near future.

A Liver-Derived Vascular Lesion: Hepatic Hemangioma or Hepatic Epithelioid Hemangioendothelioma?

Hepatic epithelioid hemangioendothelioma (EHE) is an uncommon vascular endothelial cell tumor of the liver with numerous symptoms and features. The median affected age is 41, and females are more frequently affected than men. In the following article, a 37-year-old nurse is presented who was referred to the hospital with severe right upper quadrant pain. She had been misdiagnosed with hepatic hemangioma for years, which finally turned out to be hepatic EHE. Liver transplantation has been recognized as the therapeutic method of choice due to the considerable extent of liver involvement and nonresponse to medications.

A systematic review and meta-analysis for the association of the insulin-like growth factor1 pathway genetic polymorphisms with colorectal cancer susceptibility

Background

The receptors, ligands, and associated proteins of the insulin-like growth factor (IGF) family are involved in cancer development. The IGF1 receptor and its accompanying signaling cascade are a crucial growth-regulatory mechanism that plays an important role in colorectal cancer (CRC) proliferation and differentiation. IRS1 (Insulin receptor substrate-1), a major substrate for the IGF1R, is involved in cell growth and promotes tumorigenesis. There are shreds of evidence from prior research suggesting that IGF system polymorphisms may influence susceptibility to CRC. However, the findings in this area were contradictory. Accordingly, we carried out a systematic literature search to identify all case-control, cross-sectional, and cohort studies on the association between various polymorphisms across four IGF1 pathway genes (IGF1, IGF1R, IRS1, and IRS2) and the risk of CRC.

Methods

We performed a comprehensive search strategy in PubMed, Scopus, and Web of Science databases for articles available until Aug 30, 2022. A total of 26 eligible studies with IGF1/IGF1R, IRS1 and IRS2 polymorphisms; met the inclusion criteria. All case-control studies for IGF1 rs6214C>T, IRS1 rs1801278G>A, and IRS2 rs1805097G>A comprising 22,084 cases and 29,212 controls were included in the current meta-analysis. The pooled odds ratios (ORs) with 95% confidence intervals (CIs) were used to evaluate relationships between the polymorphisms and CRC susceptibility. All statistical analyses were performed using STATA software version 14.0.

Results

The meta-analysis of available data for rs6214C>T, rs1801278G>A, and rs1805097G>A showed a significant association between these polymorphisms and an increased CRC risk in some of the comparisons studied (rs6214C>T, pooled OR for CC = 0.43, 95% CI 0.21- 0.87, P = 0.019; rs1801278G>A, OR for GA = 0.74, 95% CI 0.58-0.94, P = 0.016; rs1805097G>A, OR for GA = 0.83, 95% CI 0.71-0.96, P = 0.013). Nevertheless, the meta-analysis did not include other genetic variations in IGF1, IGF1R, IRS1, and IRS2 due to heterogeneity and limited sample size.

Conclusions

This systematic review and meta-analysis provide evidence that genetic variants in IGF1 rs6214C>T, IRS1 rs1801278G>A, and IRS2 rs1805097G>A are associated with an increased risk of CRC. These findings may contribute to a better understanding of the complex genetic mechanisms involved in CRC development and could inform future research on prevention and treatment strategies for this disease.

Principles of Molecular Utility for CMS Classification in Colorectal Cancer Management

Colorectal cancer (CRC) is the second cause of cancer-related deaths in both sexes globally and presents different clinical outcomes that are described by a range of genomic and epigenomic alterations. Despite the advancements in CRC screening plans and treatment strategies, the prognosis of CRC is dismal. In the last two decades, molecular biomarkers predictive of prognosis have been identified in CRC, although biomarkers predictive of treatment response are only available for specific biological drugs used in stage IV CRC. Translational clinical trials mainly based on "omic" strategies allowed a better understanding of the biological heterogeneity of CRCs. These studies were able to classify CRCs into subtypes mainly related to prognosis, recurrence risk, and, to some extent, also to treatment response. Accordingly, the comprehensive molecular characterizations of CRCs, including The Cancer Genome Atlas (TCGA) and consensus molecular subtype (CMS) classifications, were presented to improve the comprehension of the genomic and epigenomic landscapes of CRCs for a better patient management. The CMS classification obtained by the CRC subtyping consortium categorizes CRC into four consensus molecular subtypes (CMS1-4) characterized by different prognoses. In this review, we discussed the CMS classification in different settings with a focus on its relationships with precursor lesions, tumor immunophenotype, and gut microbiota, as well as on its role in predicting prognosis and/or response to pharmacological treatments, as a crucial step towards precision medicine.

Retroperitoneal lymphangioma as the final diagnosis of a middle-aged woman with abdominal pain: a case report

BACKGROUND

Lymphangiomas are lesions attributed to congenital malformations of the lymphatic system, or acquired chronic obstruction of the lymphatic network due to trauma, radiation, surgical manipulation, inflammation, or infection. Overall, lymaphangiomas are rare, and particularly, retroperitoneal lymphangiomas are far more uncommon per reported cases.

CASE PRESENTATION

A 49-year-old Iranian woman presented with a progressive abdominal pain since approximately 1 month before admission. She was found to have a retroperitoneal lymphangioma after a precise radiological and surgical workup.

CONCLUSION

Retroperitoneal lymphangiomas are rare lesions, sometimes indistinguishable from malignant lesions originating from pancreas and adjacent organs. Complete surgical removal and histologic evaluation of the lesion is the gold standard of treatment and diagnosis.

Management of gastrointestinal subepithelial lesions: an answer to the conflicting opinions

Subepithelial lesions, formerly known as subepithelial tumors, are incidentally discovered protrusions throughout the gastrointestinal tract with normal overlying mucosa. Studies related to the diagnosis and therapy methods are limited due to the low incidence and malignant potential of these lesions. They commonly originating from the second, third, and fourth layers (muscularis mucosa, submucosa, and muscularis propria) of the gastrointestinal wall. They are reported to be more prevalent in the stomach and esophagus than small intestine and colon. Subepithelial lesions in the stomach and duodenum are more prone to malignancy than the lesions in the esophagus. Despite different strategies in the management of subepithelial lesions based on their size and location, there is still not a unique consensus on the issue. In this review, we have attempted to introduce the most practical approach to managing gastrointestinal subepithelial lesions based on current guidelines.

A step-by-step guide to approaching colon polyps

Colorectal cancer (CRC) is considered one of the most prevalent cancers among Iranian men and women (1). Colorectal polyps, known as precursors of CRCs, are of great importance. Surveillance, locating, and removal of colorectal polyps make them the most modifiable factor apart from other genetic and environmental factors leading to CRCs. Colorectal polyps are defined as outpouchings from superficial and deep layers of mucosa of the colonic wall. They are classified as adenomas, serrated polyps, hyperplastic polyps, and hamartomas based on histological evaluation. Submucosal invasion precludes the possibility of endoscopic resection and should be ruled out via colonoscopic evaluation (2). Knowing this significance, the present study aims to present a brief review on classification, probability of endoscopic resection, complications of endoscopic polypectomy, as well as proper surveillance after polypectomy.

Small Bowel Lymphangiectasia Leading to Massive Gastrointestinal Bleeding: A Case Report

Lymphangiomas are benign lymphatic system abnormalities that can appear anywhere on the skin and mucous membranes. Lymphangiomas are caused by congenital or acquired lymphatic system disorders. In the congenital form, although the cause is unknown it is said that it is formed by the incorrect attachment of lymphatic channels to the main lymphatic drainage duct before the age of 5 years. lymphangiectasia as a subgroup of lymphangioma occurs seldom in the small bowel, especially in adults. If that happens, protein-losing enteropathy will be the most common presenting sign. In the present study, we introduce a case of a 40-year-old man without a history of any congenital or acquired diseases who was admitted to the emergency room due to long-lasting obscure overt gastrointestinal (GI) bleeding. Normal upper and lower GI endoscopies were suggestive of GI bleeding originating from the small intestine. Despite receiving iron supplements, he continued to have melena and remained anemic. Further evaluation of the small intestine by deep enteroscopy revealed multiple white spots histologically consistent with dilated lymphatics. Intestinal lymphangiectasia was eventually introduced to be the final diagnosis of the patient.

Evaluation of ASGE Criteria for Prediction of Choledocholithiasis: Can Early Endoscopic Ultrasound Utilization Make the Prediction More Accurate?

Background

ASGE predictive model for the detection of choledocholithiasis is a reasonable approach for the management of patients with cholelithiasis. Surgeons do not pursue cholecystectomy without evaluation of the biliary system when laboratory tests and diagnostic imaging evidence show biliary duct involvement. Literature revisions reveal that the prediction of choledocholithiasis based on ASGE criteria suffers from poor accuracy which results in unnecessary ERCPs. We decided to estimate the sensitivity and specificity of the ASGE predictive model for the detection of choledocholithiasis with the hope that early EUS would obviate the need for unnecessary ERCPs among highly probable patients for choledocholithiasis based on ASGE criteria.

Methods

This is a prospective intervention and control study on the accuracy of ASGE criteria for the prediction of choledocholithiasis. To evaluate the sensitivity and specificity of ASGE criteria, patients were followed in two groups of controls who were treated based on ASGE guidelines and cases who underwent primary EUS. The clinical relevance of the ASGE criteria was estimated by sensitivity and specificity using SPSS Statistics 28 software. Then, absolute risk reduction utilizing primary EUS was also calculated.

Results

The sensitivity and specificity of the ASGE predictive guideline for choledocholithiasis were estimated to be 62.31% and 51.85%, respectively. Evaluation of the ASGE guideline also revealed that patients in the intermediate probability group who finally required ERCP based on EUS results (false-negatives) were estimated to be 49.1% and patients who were predicted to require ERCP but finally did not need ERCP (false positives) were estimated to be 37.68%. The comparison of the two groups revealed the need for ERCP in about 55.56% of the primary EUS group and 77.42% in the ASGE group. Utilization of primary EUS reduced the need for ERCP by an absolute risk reduction of 0.299. (Primary Endpoint).

Conclusion

ASGE guideline is associated with the overestimation of ERCP in cholelithiasis. The usage of primary EUS will reduce the need for ERCP.

Low volume polyethylene glycol combined with senna versus high volume polyethylene glycol, which regimen is better for bowel preparation for colonoscopy? A randomized, controlled, and single‐blinded trial

Background and Aims

Bowel preparation affects the quality of colonoscopy. Reaching the optimal preparation has been a challenge for years. Polyethylene glycol (PEG) is the sole FDA‐approved substance for this purpose. However, patients find it unpleasant and often complain about its adverse effects. In this study, we aimed to reduce these complaints by lowering the amount of PEG and adding senna which is an herbal stimulant laxative.

Methods

Four hundred and eighty‐six patients were admitted for colonoscopy. Finally, 382 patients were enrolled in the study and we divided them into two groups; 186 patients were placed in which conventional high volume PEG‐alone regimen was consumed and 196 patients in which low volume PEG plus senna regimen was offered. The quality of colon preparation was compared between the two groups by independent two samples t‐test (or its corresponding nonparametric test), Fisher's exact, or χ² test in SPSS software version 22.

Results

The colon preparation quality was equally efficient in the two groups as 69.36% in the high volume PEG group and 71.94% in PEG plus senna group had adequate bowel preparation (p = 0.58). Adverse effects, like nausea, bloating, headache, and sleeplessness were significantly less in the low volume PEG plus senna group.

Conclusion

Besides the fact that bowel preparation by low volume PEG plus senna combination was noninferior to the conventional high volume PEG‐alone regimen, the side effects were much less common with the low volume PEG plus senna regimen.

Magnesium Sulfate for Prevention of Post-ERCP-Pancreatitis: A Randomized Controlled Trial

BACKGROUND

Acute pancreatitis is one of the most common complications of endoscopic retrograde cholangiopancreatography (ERCP). Studies suggest that intrapancreatic calcium has an important role in activating pancreatic enzymes; in addition, elevated intraductal pressure is required for development of pancreatitis. Magnesium sulfate (MS), as a calcium antagonist and a muscle relaxant of the Oddi sphincter, is suggested to reduce the incidence and severity of post-ERCP-pancreatitis (PEP) in this article.

METHODS

We included 270 patients who referred for ERCP between March 2017 and March 2018. They were enrolled into MS (2 g) and placebo (normal saline) groups, administered 1 hour before and 6 hours after the procedure. The ERCPs were done by fellows of gastroenterology under supervision of expert physicians. The incidence and severity of PEP were followed.

RESULTS

PEP was seen in 12 (8.9%) patients in the MS group and 17 (12.6%) in the placebo group (P value=0.33). The incidence of PEP in high risk patients group (P value=0.017).

CONCLUSION

Although the usage of MS was not able to prevent PEP in all patients enrolled in this study, but it could significantly reduce the incidence of PEP in high risk patients of intervention group in comparison with placebo group. The median length of hospital stay was also significantly lower in new drug group in contrast to placebo.

Comparison of portal hypertensive gastropathy and gastric antral vascular ectasia: an update

Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are two distinct entities that are frequently mistaken with each other, because they present with similar manifestations. This issue may cause catastrophic outcomes, as each one of them has a unique pathophysiology, thereby making their management approaches completely different. There are clinical clues that help physicians distinguish these two. Direct vision via upper endoscopy is often mandatory to establish the diagnosis, and sometimes biopsy is required. In this review, we sought to discuss different aspects of both conditions and highlight clinical evidence that may help in identifying and managing the disease appropriately.

Education case: a case-based approach to overlap syndromes in autoimmune liver disease in patient with ulcerative colitis

Simultaneous occurrence of immune-based gastrointestinal diseases and autoimmune hepatitis, although not common, is of clinical importance. Some clinical and laboratory findings such as severe pruritus and elevated alkaline phosphatase raise suspicion of a biliary disease which overlaps autoimmune hepatitis. A strong clinical suspicion of overlap syndrome in a patient with autoimmune hepatitis prompts more diagnostic evaluations like MRCP, liver biopsy, and secondary laboratory tests. Patients who fall into the category of overlap syndrome proceed with timely monitoring of known complications including colorectal carcinomas, cholangiocarcinomas, and gallbladder cancers. It is strongly recommended that all simultaneous immune-based involvements be searched prior to labeling a patient as having pure autoimmune hepatitis. The current study attempted to express all challenges about a case with overlap syndrome referred to the gastroenterology ward of Taleghani Hospital and to review the latest articles and related guidelines about the diagnosis, treatment, complications, and surveillance of the mentioned patient with autoimmune hepatitis (AIH), primary sclerosing cholangitis (PSC), and inflammatory bowel disease (IBD).

Transverse colon varices

Portal hypertension associated with liver cirrhosis usually leads to gastroesophageal varices; however, ectopic varices secondary to liver cirrhosis are not common, especially colonic varices which occur with a low frequency. We are going to discuss the case of a 75-year-old man with liver (HBV) cirrhosis who was admitted to the hospital with rectorrhagia. Colonoscopy revealed evidence of acute bleeding in tortuous colonic varices. The band ligation performed during the colonoscopy had failed to control the bleeding. The patient was referred to Taleghani Hospital in Tehran, and rectorrhagia was subsequently successfully controlled by BRTO technique (balloon-occluded retrograded transvenous obliteration).

A Case Series of Variable Manifestations of COVID-19 in Liver Transplant Recipients

Severe acute respiratory syndrome coronavirus-2 (SARS-COV-2) that is known as COVID-19 is a new emerging respiratory infection attributed to novel coronavirus, firstly introduced in Wuhan, China, at the end of 2019. This infection is still of great concern because of various presentations of the disease, which are not fully understood. The manifestations of this virus among liver transplanted patients would be more challenging in the setting of immunosuppression. The focus of this study is to introduce different presentations of this virus in five liver transplant recipients referred to the gastroenterology ward of Taleghani Hospital, a teaching referral hospital in Tehran, Iran. These patients were started on different types of therapies for coronavirus infection, from only supportive care up to remdisivir infusion and hemoperfusion based on the severity of the disease. Additionally, they were advised to continue all their immunosuppressant agents with adjustment except for CellCept that was withheld.

A Rare Cause of Ascites in a Young Woman Mimicking Peritoneal Carcinomatosis

Peritoneal granulomatous reaction to foreign body-like materials of a dermoid cyst is a rare condition and has always been challenging in diagnosis for physicians. Macroscopic view of granulomatous peritoneum, which mimics peritoneal carcinomatosis or peritoneal seeding originating from ovarian carcinoma, necessitates a detailed microscopic evaluation of peritoneum, which shows multinucleated giant cells and granuloma formation indicating a foreign body reaction in the peritoneum. To avoid unnecessary radical surgeries and salvage chemotherapies in these patients, a detailed microscopic evaluation of their peritoneum is necessary. The present study introduces a 23-year-old woman with new-onset ascites and an elevation of CA125 level suspicious of ovarian carcinoma but with a peritoneal microscopic finding pathognomonic of foreign body reaction.

An uncommon presentation of hepatic hydatid cyst leading to biliary cirrhosis and portal hypertension

Hydatid disease is an ongoing issue in endemic areas. Hydatid cysts can be seen in any organ but, liver is one of the most common involved organs. Cystobiliary communication as an overwhelming complication of hepatic hydatid cysts can contribute to the obstructive jaundice, cholangitis, sepsis and even biliary cirrhosis if left untreated. The patient we are trying to present is a 61-year-old farmer who presented with obstructive jaundice, multiple common bile duct stones and biliary cirrhosis attributed to a long-lasting untreated hepatic hydatid cyst. Portal hypertension is introduced to be an uncommon presentation of hydatid cyst. Extrinsic compression of the porta hepatis and obstruction of inferior vena cava are amongst major causes of hydatidosis leading up to portal hypertension as reported in the literature. Portal hypertension in the presented case is proposed to emerge from long-lasting cystobiliary communication ending in biliary cirrhosis.

An algorithmic approach to gastrointestinal bleeding in patients receiving antithrombotic agents

Gastrointestinal bleeding is an overwhelming complication of patients taking antithrombotic agents. These drugs pose a challenge to physicians in the management of bleeding to establish hemostasis without putting these patients at a higher risk for thromboembolism. This study aims to propose an algorithmic approach to four major groups of patients receiving antithrombotic agents (single antiplatelet agents, dual antiplatelet agents, anticoagulants and direct oral anticoagulants) to decide when and how these drugs should be held or restarted to offset between the risk of re-bleeding and thromboembolism. Four case-based algorithms are proposed in this article based on some relevant articles. Having designed four case-based algorithms, we are hoping to guide physicians who face a dilemma on the management of patients receiving antithrombotics when gastrointestinal bleeding occurs. Patients using antithrombotics referred for gastrointestinal bleeding were stratified into four groups based on the medication which is used as an antithrombotic agent and four algorithms were designed which are presented here. We have made an attempt to have a stepwise approach to four cases relevant to the study and have an evaluation on the management of their antithrombotic agents during an episode of gastrointestinal bleeding. It is widely accepted that antithrombotic agents should be restarted as soon as possible after the establishment of hemostasis in a patient taking antithrombotics referring for gastrointestinal bleeding. The time for resuming these drugs is different based on the severity of bleeding, the probability of thromboembolic events, and the nature of the antithrombotic medication which is used by the patient.

Presentation of COVID-19 in a liver transplant recipient

Diarrhea is common after liver transplant. Although the majority of episodes are experienced during the first year of transplantation, they can occur any time after the procedure. Diarrhea can impose a major risk of morbidity and mortality on transplanted patients; so a careful evaluation is required to manage it. There are few studies highlighting the gastrointestinal manifestations of COVID-19, in particular among immunosuppressed patients. The predominant respiratory symptoms of coronavirus cause GI aspects of the virus to be overlooked. This study represents a young woman with a history of liver transplant who was referred to the hospital because of diarrhea, fever, and abdominal pain attributed to coronavirus infection.

A Rare Cause of Gastrointestinal Bleeding in a 65-Year-Old Man with History of Polycythemia Vera

Polycythemia vera (PV) is classified as a myeloproliferative disorder (MPD). Such patients are prone to both thrombotic and hemorrhagic events. Although gastrointestinal (GI) bleeding is not a prominent manifestation of PV, it would be life threatening and necessitating hospital admission and blood transfusion if it occurs. GI hemorrhage in these patients may be due to Aspirin usage, peptic ulcer disease (PUD), acquired Von Willbrand disease, Dieulafoy lesion (DL), Mallory Weiss tear, and esophageal and gastric varices. DL is an enlarged, thick-walled artery in the muscularis mucosa with a small submucosal defect. In this case report, we describe a 65-year-old man with history of PV presented with a massive upper GI bleeding. After a therapeutic endoscopic hemostasis failure and reoccurrence of bleeding during hospital admission, an abdominal computed tomography (CT) was ordered, which revealed an aberrant artery originated from aorta directly into the stomach. An angiographic embolization was considered for the patient, which was successfully performed. Our patient was complicated by splenic infarction due to splenic collateral arteries embolization and the overwhelming thrombotic tendency of the patient himself due to the history of PV. Fortunately, our patient's signs and symptoms responded to supportive therapies and eventually he discharged well.

Clinical and Pathological Features of Ulcerative Colitis in Patients with and without Clostridium Difficile Infection; An Observational Study

BACKGROUND

A dramatic rise in the rate of clostridium difficile infection (CDI) in patients with inflammatory bowel disease (IBD) has been reported in recent years.

METHODS

In this observational case control study, 65 patients were included and were divided into two groups of IBD + CDI as case group and IBD without CDI as control group.

RESULTS

35 patients who had positive test for clostridium difficile were assigned to the case group. The control group consisted of 30 patients with negative test for clostridium difficile. Pancolitis was seen in the cases more statistically significant than the controls and proctitis was seen more among the controls than the cases (p = 0.001). The cases were on immunosuppressive (p = 0.001) and antibiotic (p = 0.02) therapy more than the controls. Colonoscopic findings revealed more severe and extensive inflammation among the cases versus milder inflammation among the controls, but these differences were not statistically significant (p = 0.2). Colectomy was seen in 10% of controls and none of the cases and this difference was statistically significant (p value = 0.05). More fecal calprotectin were seen among the cases than the controls and this difference was statistically significant (p < 0.05)

CONCLUSION

This study showed more clostridium difficile infection among the patients on antibiotic or immunosuppressive therapy. Pathological investigation revealed more severe and extensive inflammation among the cases than the controls. Cases had clinically more severe signs and symptoms with higher mayo scores than the controls. ESR (Erythrocyte sedimentation rate) and fecal calprotectin were higher in patients with positive clostridium difficile infection and serum albumin was lower in such patients.