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IntroductionPatients with inflammatory bowel disease (IBD) are at a greater risk for the recurrence of Clostridioides difficile infection (rCDI) that is triggered by intestinal microbiota dysbiosis. Fecal microbiota transplantation (FMT) has emerged as a highly effective therapeutic option for this complication. However, little is known about the impact of FMT on intestinal microbiota alterations in rCDI patients suffering from IBD. In this study, we aimed to investigate post-FMT intestinal microbiota alterations in Iranian rCDI patients with underlying IBD.MethodsA total of 21 fecal samples were collected including 14 samples pre- and post-FMT and 7 samples from healthy donors. Microbial analysis was performed by quantitative real-time PCR (RT-qPCR) assay targeting the 16S rRNA gene. The pre-FMT profile and composition of the fecal microbiota were compared to the microbial changes of samples collected 28 days after FMT.Results and discussionOverall, the fecal microbiota profile of recipients was more similar to donor samples after the transplantation. We observed a significant increase in the relative abundance of Bacteroidetes post-FMT, compared to the pre-FMT microbial profile. Furthermore, there were remarkable differences between the microbial profile of pre-FMT, post-FMT, and healthy donor samples by PCoA analysis based on the ordination distance. This study demonstrates FMT as a safe and effective approach to restore the indigenous composition of the intestinal microbiota in rCDI patients and ultimately results in the treatment of concurrent IBD.

Background: Evolving evidence indicates the role of vitamin D deficiency in the progression of IBD and its impact on the severity of the disease, but it remains unclear whether vitamin D deficiency causes IBD or vice versa. Methods: This cross-sectional study was conducted to determine the serum levels of vitamin D and its effects on the severity of disease in patients with inflammatory bowel disease in the Imam Khomeini Hospital complex. A questionnaire containing demographic information, records on the use of supplements and medications, disease complications, and criteria for determining the severity of the disease based on the Mayo score and Crohn’s Disease Activity Index (CDAI) and 25 hydroxy vitamin D levels was completed and evaluated. Results: Of the 101 participants, 21 were with Crohn’s disease and 80 had ulcerative colitis. The mean age of Crohn’s patients was 33.80±9.5 years and ulcerative colitis was 38.43±10.2 years. Among patients with ulcerative colitis, 37 (46.8%) had a mayo score less than 3 and 42 (53.2%) were 3 and more. Mean vitamin D in the mayo score less than 3 was 32.14 and the mayo score 3 and more was 23.99. Of the Crohn’s patients, 12 (57.1%) were in the recovery phase and 9 (52.9%) were in a non-recovery phase. The mean of vitamin D in the recovery phase was 29.10 and in the others was 27.04 Conclusion: There is a significant relationship between the level of vitamin D supplementation, the final value of CDAI, and the identification of the patients with the Mayo score.

Introduction: Cytolethal distending toxin (Cdt) is one of the bacterial toxins that present in a variety of Gram-negative human pathogens, such as E. coli, Salmonella spp., and Campylobacter spp. CDT composed of three subunits encoded by three adjacent genes, including cdtA, cdtB and cdtC. It is approved that cdtB had toxic activity and caused DNA damage of the host cell. Despite its presence in different bacterial species, role of Cdt in acute and chronic infections, such as gastroenteritis and irritable bowel syndrome (IBS) is unclear. To analyze this correlation, we studied the prevalence of cdtB among different enteropathogenic bacteria in patients with gastroenteritis and IBS compared with healthy people.Materials and Methods: In this cross-sectional descriptive study, 230 stool samples were collected from patients with gastroenteritis, IBS, and healthy people. The presence of Cdt-B encoding bacteria, including Escherichia coli, Campylobacter spp., Yersinia entercolitica, Providencia alkalifacience, and Salmonella enterica was examined by polymerase chain reaction using genus specific primers. Results: Out of 230 stool samples, Cdt-B encoding Campylobacter spp. were found in 34.6% (52/150), 6.25% (5/80), and 4% (2/50) of the patients with gastroenteritis, IBS, and the control group, respectively. Carriage of Cdt-B encoding Salmonella enterica was characterized among 5.3% (8/150) of the patients with gastroenteritis and 17.5% (14/80) of the IBS patients. Although none of the patients carried cdtB of E. coli and Providencia spp., cdtB of Y. enterocolitica was detected in 1 of the patients with gastroenteritis (0.6%). Statistical analysis showed significant correlation between infection with CdtB-encoding Campylobacter spp. and IBS-D subtype. No significant correlation was found between infection with Cdt-B encoding bacteria, and other clinical and demographic data.Conclusion: Our results confirmed relatively higher frequency of Cdt-B encoding bacteria in the intestine of IBS patients and those with gastroenteritis compared with healthy individuals. Regarding the frequency of Cdt-B encoding Salmonella and Campylobacter bacteria, it was proposed that infection with these enteropathogens could be considered as a risk factor for the development or progression of IBS among the Iranian patients. Further studies are needed to establish this involvemet.

In this study we indicated that impaired serological responses to SARS-CoV-2 infection among patients with IBD, could have significant implications for this group of patients and should be considered in vaccination program.

Coronavirus disease 2019 (COVID-19) had caused pandemia with a high rate of mortality and morbidity. Lung involvement is the main cause of mortality, but central nervous system and cardiac disease, and thromboemboli may participate in increasing mortality. A wide spectrum of organs involvement and complication has been reported as data gathering during the pandemia has progressed. We report a 69-year-old man who was admitted to Imam Khomeini hospital in Tehran and complained of severe abdominal pain and fever. He had been admitted 10 days earlier because of dyspnea and fever. At the first admission, based on the findings in the lung computed tomography (CT) and a positive nasopharyngeal polymerase chain reaction (PCR) test for COVID-19, he was treated with intravenous remdesivir for 5 days and prophylactic anti-coagulant heparin during hospital admission. Two days before the new admission, he was discharged with relative recovery. During the new admission, because of the absence of hypoxemia and leukocytosis diagnostic approach to abdominal pain was planned. In abdominal imaging, evidence of bowel perforation appeared. In laparotomy, suppurative peritonitis and proximal jejunal perforation without definite etiology were seen, and bowel resection and primary anastomosis were done. After 5 days, the patient was discharged in good condition. This case is reported to inform that bowel perforation due to ischemia or vasculitis may complicate the course of COVID-19 and, in cases of gastrointestinal symptoms, should be considered.

An alarmingly increasing number of outbreaks caused by contaminated gastrointestinal (GI) endoscopes are being reported as a particularly concerning issue. This study is the first large-scale multicenter survey to evaluate the contamination of GI endoscopes in Tehran, Iran. This multicenter study was conducted among 15 tertiary referral and specialized gastrointestinal settings. Reprocessed GI endoscopes were sampled by the sequence of the flush-brush-flush method. Bacterial and viral contamination, as well as antimicrobial resistance, were explored by culture and molecular assays. A total of 133 reprocessed and ready-to-use GI endoscopes were investigated. In phase I and phase II, 47% and 32%, respectively, of the GI endoscopes were determined to be contaminated. GI flora was the most prevalent contaminant isolated from GI endoscopes, in which the most predominant bacteria were Pseudomonas aeruginosa, Escherichia coli, and Klebsiella pneumoniae, in both phase I and II evaluations. The majority of the isolated bacteria in the current study were considered multidrug-resistant organisms (MDROs). More importantly, we recovered carbapenem-resistant nonfermentative Gram-negative bacilli (CRNFGNB), carbapenem-resistant

No previous investigation has summarized findings from prospective cohort studies on the association between dietary intake of fiber, fruit, and vegetables and risk of inflammatory bowel disease (IBD). Dietary fiber and its major sources can influence the risk of IBD by modulation of the gut microbiota. This study summarizes findings from published cohort studies on the association between dietary fiber, fruit, and vegetable consumption and risk of IBD. Relevant articles published up to January 2019 were searched via PubMed, MEDLINE, Scopus, Embase, Cochrane Library, and Google Scholar. All prospective cohort studies investigating the association between dietary fiber, fruit, and vegetable intake and risk of IBD were included. Combining 7 effect sizes from 6 studies, no significant association was found between dietary intake of fiber and risk of ulcerative colitis (UC) (RR: 1.09; 95% CI: 0.88, 1.34). However, a significant inverse association was found between dietary fiber intake and risk of Crohn disease (CD) (RR: 0.59; 95% CI: 0.46, 0.74), based on 5 studies with 6 effect sizes. Pooling information from 4 studies, we found a significant protective association between dietary intake of fruit and risk of UC (RR: 0.69; 95% CI: 0.55, 0.86) and CD (RR: 0.47; 95% CI: 0.38, 0.58). We also found a significant inverse association between vegetable consumption and risk of UC (RR: 0.56; 95% CI: 0.48, 0.66) and CD (RR: 0.52; 95% CI: 0.46, 0.59). In conclusion, dietary intake of fruit and vegetables was inversely associated with risk of IBD and its subtypes. Dietary fiber intake was also inversely associated with incidence of IBD and CD, but not with UC. Further studies are warranted to examine the association of other fiber-rich foods with IBD.

Colonic malakoplakia is a rare chronic granulomatous disease that can involve many organs such as the lung, brain, pancreas, bone, adrenal glands, and genitourinary tract. The most common site of involvement outside the genitourinary tract is the gastrointestinal tract. We report a case of colonic malakoplakia who presented with unintentional weight loss, abdominal pain, and chronic diarrhea. There was a history of lupus nephritis and Sjogren disease, receiving various immunosuppressive drugs. Physical examination other than pallor was unremarkable in this patient, but colonoscopy revealed multiple polyps in the rectum with a cobblestone appearance in the cecum. The histopathological assessment showed infiltration of numerous lymphoplasma cells and neutrophils in the lamina propria, and rare Michaelis-Gutmann bodies were seen in foamy epithelioid histiocytes. These findings are suggestive of malakoplakia. We treated the patient with tetracycline, and after 3 months of follow-up, clinical improvement was achieved.

The coronavirus associated disease 2019 (COVID-19) caused by the SARS-CoV-2 virus has rapidly spread all around the world and became pandemic in March 2020. Data on liver transplantation and chronic liver disease during the pandemic has remained scarce, and there is little information on whether immunosuppressed patients are at higher risk of developing severe COVID-19 infection. This review provides information for health care providers who care for patients with liver transplantation and chronic liver diseases.

Genetic studies have illustrated that killer cell immunoglobulin-like receptor (KIR) genes could participate in various autoimmune disorders. We aimed to clarify the role of KIR genes, HLA ligands, HLA-KIR interactions, and their genotypes in inflammatory bowel disease (IBD) susceptibility. The study population was composed of 183 IBD subjects, comprising 100 ulcerative colitis (UC) patients, 83 Crohn’s disease (CD) patients, and 274 healthy subjects. Polymerase chain reaction with sequence-specific primers (PCR-SSP) was used to evaluate the absence or presence of the 15 KIR genes, 5 HLA class I ligands, and 2 pseudogenes. We did not find any significant difference in allele frequency of KIRs and pseudogenes between IBD patients and healthy controls. In the case of HLA genes, there was a significant difference in HLA-B-Bw4Thr80 frequency between UC patients and healthy controls (P=0.03, OR=0.06, 95%CI=0.008-0.4). Furthermore, we found a significant difference in HLA-C1Asn80 frequency between CD patients and healthy controls (P=0.04, OR=0.49, 95% CI=0.3-0.8). In the full-array combination of KIR genes, there was no significant frequency difference between UC patients and healthy controls, while two KIR genotypes showed a significant susceptible association with CD. Our data do not support a strong role of NK cells in IBD susceptibility, but it does not rule out a role for KIR variability in IBD patients. However, there are some protective associations such as Bw4 alleles; these associations may be due to the interaction of the alleles to TCRs rather than KIRs.

Background: Ulcerative colitis (UC) is specified by a chronic mucosal inflammation that has a deleterious impact on the quality of life (QoL). Coenzyme Q10 (CoQ10) appears to influence disease activity by its obvious properties. Therefore, the current research intends to assess the impacts of CoQ10 on QoL, disease activity, and blood pressure in UC patients. Methods: This clinical trial performed on men and women with UC in 2017 who were attended the gastrointestinal center of Hazrat Rasool Akram Hospital and private clinic. Eighty-eight UC patients were randomly allocated to receive either CoQ10 (200 mg/day) or placebo for 8 weeks. The anthropometric parameters, blood pressure, inflammatory bowel disease questionnaire-32 (IBDQ-32) score, and the Simple Clinical Colitis Activity Index (SCCAI) score were measured pre and post-intervention. P-value

Background: Crohn's disease (CD) has a chronic course, which its recurrence varies widely among different patients. In this study we prospectively analyzed blood samples of 19 CD patients. Alteration in transcription of inflammatory and anti-inflammatory cytokines was analyzed compared with household members after three month follow up. Methods: CD patients were diagnosed based on clinical symptoms, endoscopic and histopathologic characteristics. Nineteen CD patients and their households were evaluated from Jun 2019 to Feb 2021 at Tehran university hospitals. CD activity score, biological, clinical and demographic data of the patients were recorded at two time point intervals. Bacteriological tests were done using aerobic and anaerobic blood cultures. To investigate transcriptional alterations, peripheral blood mononuclear cells (PBMCs) were isolated using Ficol centrifugation method and relative quantitative real-time PCR was done to determine the expression level of IFN-γ, TNF-α, IL10, and FOXP3 cytokines. Results: Our results showed a correlation between fecal calprotectin level (709.8 ± 554.6), C-reactive protein concentration (18.1 ± 15.9), and erythrocyte sedimentation rate (30.4 ± 17.9) with disease activity (Flare/remission). IL10 and Foxp3 anti-inflammatory gene’s expression were significantly (P = 0.003 for IL10 and P = 0.008 Foxp3) higher during the flare and remission in patients with active disease respectively. Bacteriological examination showed infection with Streptococcus spp. and Clostridium spp. in two CD patients during flares, which was correlated with upregulation and down-regulation of IL10, TNF-α, IFN-γ and FOXP3 proteins, respectively. Conclusion: Occurrence of bacteremia, and higher amount of CAP, CRP and ESR are correlated with higher level of transcription for inflammatory cytokines, which could effectively reflect the disease activity. Raise in FoxP3 transcription proposed change in Treg sub-population in PBMC or its activity during the CD remission phase.

Background/Aims: A recent study revealed increasing incidence and prevalence of inflammatory bowel disease (IBD) in Iran. The Iranian Registry of Crohn’s and Colitis (IRCC) was designed recently to answer the needs. We reported the design, methods of data collection, and aims of IRCC in this paper. Methods: IRCC is a multicenter prospective registry, which is established with collaboration of more than 100 gastroenterologists from different provinces of Iran. Minimum data set for IRCC was defined according to an international consensus on standard set of outcomes for IBD. A pilot feasibility study was performed on 553 IBD patients with a web-based questionnaire. The reliability of questionnaire evaluated by Cronbach’s α. Results: All sections of questionnaire had Cronbach’s α of more than 0.6. In pilot study, 312 of participants (56.4%) were male and mean age was 38 years (standard deviation=12.8) and 378 patients (68.35%) had ulcerative colitis, 303 subjects (54,7%) had college education and 358 patients (64.74%) were of Fars ethnicity. We found that 68 (12.3%), 44 (7.9%), and 13 (2.3%) of participants were smok ers, hookah and opium users, respectively. History of appendectomy was reported in 58 of patients (10.48%). The most common medication was 5-aminosalicylate (94.39%). Conclusions: To the best of our knowledge, IRCC is the first national IBD registry in the Middle East and could become a reliable infrastructure for national and international research on IBD. IRCC will improve the quality of care of IBD patients and provide national information for policy makers to better plan for controlling IBD in Iran. (Intest Res 2019;17:330-339)

Background and Aims: The incidence of Inflammatory bowel disease (IBD), including Crohn’s disease (CD) and Ulcerative colitis (UC), is rising in Asian populations. We undertook a cross-population study to explore whether genetic risk scores (GRS) of IBD, CD and UC could explain their occurrence, and whether they can be used to predict disease occurrence in general populations from East Asia (EA) and Central Asia (CA). Methods We studied 9,698 subjects – 4,733 IBD patients (2,003 CD; 2,730 UC) and 4,965 matched controls – who had been genotyped using Immunochip. The subjects were from three East Asian (Japan, South Korea and China) and two Central Asian populations (India and Iran). We generated GRS for each population by combining information from up to 201 genome-wide significant IBD-associated variants to summarize the total load of genetic risk for each phenotype. We then estimated the explained variance and predictability of IBD using the GRS. Results IBD GRS could explain up to 4.40% and 4.14% of IBD variance at a significant level in East Asian and Central Asian populations, respectively, but, given a prevalence of 0.01% and 0.04% for IBD, these yield limited predictive probability. GRS for CD and UC separately proved less significant than GRS for IBD. Conclusion GRS alone can explain only a limited percentage of disease occurrence (

BACKGROUND Infiltration of IgG4 positive plasma cells has been detected in the colonic mucosa of patients with ulcerative colitis (UC). The aim of the study was to investigate the association between colonic mucosal infiltration of IgG4 plasma cells and the presence, activity, extension, and duration of UC. METHODS In this case-control study (2009-2014), 102 subjects (84 with UC/18 controls) were enrolled. Clinical records and rectosigmoid biopsies of UC patients were selected, and biopsies were stained with IgG4 monoclonal antibodies. IgG4 positive plasma cells were counted by a single pathologist. RESULTS Amongst 84 patients with UC, 73.8% had UC without primary sclerosing cholangitis (PSC), and 26.2% had UC with PSC. IgG4 plasma cells were seen in 35 (41.7%) patients with UC and 0% of controls (p = 0.001). The mean amount of IgG4 containing plasma cells was significantly different between active and inactive patients with UC, although it was not significantly different between UC patients with and without PSC. The presence of IgG4 infiltration was significantly associated with the extension and duration of the disease. Furthermore, IgG4 count had a sensitivity/specificity of 78.6%/83.3% for the diagnosis of UC. CONCLUSION Our study revealed the diagnostic role of IgG4 plasma cells in the colonic mucosa of patients with UC and its association with activity, extension, and duration of disease.

Background: Constipation is a common disorder, and its management imposes a significant health burden. Integration of complementary and alternative medicine into the current health system may result in beneficial outcomes. Objective: This study aimed to evaluate the efficacy and safety of a Persian medicine preparation (Jalinous capsule) on functional constipation. Jalinous capsule is a combination of rose (Rosa damascena), mastic (Pistacia lentiscus), Aloe vera (Aloe barbadensis), and turpeth (Ipomoea turpethum). Methods: From January to December 2019, 126 patients aged 18 - 50 with functional constipation according to Rome IV criteria referred to Imam Khomeini hospital's gastrointestinal disease clinic were blindly randomized into "Jalinous" capsule group and placebo group for four weeks. Both groups received psyllium indeed. The patients were followed up at weeks two and four of the treatment and four weeks after the termination of the intervention. Results: Although the frequency of defecation, percentage of incomplete defecation and evacuation, straining during defecation, using manual maneuver to facilitate evacuation and defecation time showed significant improvement in both groups (P < 0.001), improvements in the intervention group were significantly more than in control group (P < 0.001). At the end of the second and fourth weeks of taking the drug and four weeks after stopping the drugs, the patients in the intervention group reported less frequent hard stool form in comparison to the patients in the control group (P < 0.001). Their overall self-reported improvement in symptoms after the treatment was significantly higher than the patients in the placebo group (P < 0.001). Adverse effects were not serious and mostly were transient. Conclusion: "Jalinous" capsule is an effective and safe treatment for functional constipation in adults, but more studies are needed to make confident conclusions.

Background: In a resource-demanding COVID-19 pandemic, guidelines can free up health care resources needed for providing better care to those with COVID-19 and other patients. This study was performed to design a guideline to manage patients with colorectal cancers during the COVID-19pandemic. Methods: To design this guideline, major topics and headings of colon and rectal cancers (CRC) were selected and included. Based on the extent of COVID-19 infection in the community and availability of hospital resources, the guideline has been designed for 2 major COVID-19 phases. Several multidisciplinary discussion sessions were held to review the comments of experts, finalize the data, and write the guideline. Results: This guideline has been prepared in 2 main COVID-19 phases of the community/hospital. Phase A refers to the condition where a large number of COVID-19 patients are admitted to the hospital, but limited surgical ICU beds and facilities are still accessible. In phase B, many people are affected by COVID-19, and all hospital resources are allocated for COVID 19 patients. In phase A, 4 major groups are discussed, including malignant and suspicious colorectal polyps, colon cancers, rectal cancers, and recurrent cancers. The approach to emergent cases, including obstruction, bleeding, and perforation, will be presented in phase B. Conclusion: This guideline is a comprehensive instruction on the approach to colorectal cancers during the COVID-19 pandemic that covers the major topics of colon and rectal cancers in detail.

BACKGROUND The anti-TNF drugs are shown to be highly effective in treatment of patients with moderate-tosevere inflammatory bowel disease (IBD). Here, we aimed to assess the efficacy and safety of antiTNF therapy at the national level. METHODS IBD patients aged 15 > years who received Infliximab and/or CinnoRA® between 2013 to July 2018 were identified. The data extracted from medical dossier and telephonic interview. The efficacy of therapy was defined as time to drug discontinuation or need for IBD-related surgery. The safety was assessed based on patient’s reported adverse events. RESULTS We included 315 patients. The mean age of patients was 37.2 years and 62.2% of them developed the disease before age 30 years. Involvement of masculoskeletal system was reported in 7.3% of patients. Partial and complete response to Anti-TNF therapy was seen in 67% of patients. About 16% of patients did not respond to induction therapy and 16.9% of patients lost their response to Anti-TNF during one year. No serious adverse events, serious opportunistic infection, tuberculosis and malignancies reported by patients. Two patients reported pneumonia. CONCLUSION This study for the first time in our country, provides the evidences for efficacy of anti-TNF therapy in moderate to severe IBD patients.

BACKGROUND Alopecia areata is an immune mediated inflammatory hair loss, which occurs in all ethnic and age groups, and both sexes. However no significant etiology has been known for this disease. Helicobacter pylori (H. pylori), is an organism colonized in gastric mucosa. This bacterium has been associated with certain extra-digestive dermatological conditions. The causal relationship between alopecia areata and H. pylori infection has been discussed in literature. Therefore, we conducted this study to evaluate the prevalence of H. pylori infection in patients with alopecia areata and assess the risk of this infection in patients with this disease in order to determine its potential roles in the physiopathology of this disease. METHODS Between 2014 and 2015, we prospectively studied 81 patients with alopecia areata and 81 healthy volunteers with similar age and sex. Patients without any history of H. pylori infection were included in the study and underwent urease breath test. All results were analyzed using SPSS software (version 21.0) and p value

BACKGROUND It is hypothesized that migraine may be related to inflammatory bowel disease (IBD), therefore in this cross-sectional study we evaluated the prevalence of migraine in patients with IBD. METHODS In this cross-sectional study 80 patients with IBD and 80 patients without IBD referring to gastroenterology office (Dr Daryani’s office) from May to January 2014 were evaluated regarding the prevalence of migraine, severity of migraine based on Headache Impact Test (HIT-6), and habits related to headache. RESULTS 160 participants with the mean age of 35 years were evaluated. The prevalence of migraine in the case group was significantly higher than the control (21.3% vs. 8.8%, p =0.027). Moreover duration of each attack (hours) in IBD group was significantly higher than the control group ( p

Background In the absence of properly designed studies, the clinical implication of genetic findings in Inflammatory Bowel Disease (IBD) is a matter of persistent debate especially in Asian population where the prevalence of IBD including Crohn’s Disease (CD) and Ulcerative Colitis (UC) is rising. We aimed to investigate the predictability of IBD, CD, and UC by the means of Genetic Risk Score (GRS), in yet unaffected high-risk individuals from East Asia (EA) and Central Asia (CA). Methods This present study included 9,698 subjects, consisting of 2,003 CD, 2,730 UC and 4,965 countries, age and gender-matched controls, genotyped on the Immunochip array of three EA (Japan, South-Korea and China) and two CA countries (India and Iran). We generated a multi-locus GRS for each population by combining information from up to 201 known genome-wide significant IBD associated variants to summarize a total load of genetic risk for each phenotype. We estimated explained variance and predictability of IBD, CD, and UC by GRS. We shuffled the EA data into: training set including two out of the three EA populations to build a model to calculate the odds ratio (OR) for each IBD variants, and a test set including the third population for the validation of predictive model built in the training set. For Indian and Iranian populations, we used the previously estimated ORs for the Caucasian population, to build GRS and test the predictive model in these two populations. Results GRS of IBD could significantly explain up to 4.40% and 4.14% of IBD variance in EA and CA populations but given a prevalence of 0.01% and 0.04% for IBD it yields to a negligible predictive probability up to 8.8x10-4 and 5.52x10-4. GRS of CD and UC could significantly explain CD and UC to a lesser extent compared to IBD given a lower prevalence of CD and UC (figure 1). Conclusions The present study shows that genetic findings based on Trans-ethnic analyses are applicable across Asian populations. GRS alone can explain a limited percentage of disease occurrence in general population (

Background: The extent of antibiotic resistance among Helicobacter pylori strains influences current clinical therapeutic regimens in each region. Objectives: This cross-sectional study aimed to determine the resistance property and minimum inhibitory concentration (MIC50-90) of Helicobacter pylori strains toward metronidazole, clarithromycin, and ciprofloxacin in patients with distinct gastric histopathological changes in Tehran, Iran. Methods: This study was conducted on 170 patients suffering from gastric complications in three hospitals in Tehran from October 2014 until March 2015. Two separate biopsy samples were collected from each patient and used for pathological and microbiological examinations. Antimicrobial susceptibility tests were performed by agar dilution method according to the CLSI guidelines. The MIC values and susceptibility to varying concentrations of metronidazole (4 to 64 µg/mL), ciprofloxacin (0.5 to 16 µg/mL), and clarithromycin (0.25 to 16 µg/mL) were determined based on EUCAST recommendations. Results: Our results indicated the infection with H. pylori in a frequency of 32% (55/170) among the study patients (female, 51% and male, 49%). Endoscopic findings indicated that 42% of the patients suffered from peptic ulcers, 33% from duodenal ulcers, and 25% with a non-ulcer disease. Pathological findings indicated 58% of the patients had chronic gastritis, 33% had active chronic gastritis, and 9% suffered from intestinal metaplasia. In terms of antibiotic susceptibility, nearly 76.3%, 49%, and 45.5% of the strains were resistant to metronidazole, clarithromycin, and ciprofloxacin, respectively. The MIC values at which the growth of 50% and 90% of the strains was inhibited (MIC50-90) were 32 - 64 µg/mL for metronidazole, 0.5 - 16 µg/mL for clarithromycin, and 2 - 16 µg/mL for ciprofloxacin. Conclusions: The overall resistance levels were relatively high among the study patients. Accordingly, the administration of other anti-Helicobacter drugs, as well as more appropriate therapeutic regimens based on laboratory results, is recommended in patients with a history of treatment failure.

BACKGROUND According to recent studies comparing magnetic resonance enterography (MRE) with ileocolonoscopy for assessing inflammation of small bowel and colonic segments in adults with active Crohn's disease (CD), we aimed to compare the accuracy of these two diagnostic methods in Iranian population. METHODS During 2013-2014 a follow-up study was done on 30 patients with active CD in a gastroenterology clinic affiliated to Tehran University of Medical Sciences. MRE and ileocolonoscopy were performed for all the patients. All statistical analyses were performed using SPSS (version 18) and p-value

BACKGROUND Alopecia areata is an immune mediated inflammatory hair loss, which occurs in all ethnic and age groups, and both sexes. However no significant etiology has been known for this disease. Helicobacter pylori (H. pylori) , is an organism colonized in gastric mucosa. This bacterium has been associated with certain extra-digestive dermatological conditions. The causal relationship between alopecia areata and H. pylori infection has been discussed in literature. Therefore, we conducted this study to evaluate the prevalence of H. pylori infection in patients with alopecia areata and assess the risk of this infection in patients with this disease in order to determine its potential roles in the physiopathology of this disease. METHODS Between 2014 and 2015, we prospectively studied 81 patients with alopecia areata and 81 healthy volunteers with similar age and sex. Patients without any history of H. pylori infection were included in the study and underwent urease breath test. All results were analyzed using SPSS software (version 21.0) and p value

Background & Aim: Recent studies have suggested the therapeutic effect of antimicrobial agents on primary sclerosing cholangitis (PSC). Therefore, we aimed to evaluate the efficacy of oral vancomycin in patients with PSC. Method: A triple blinded, randomized, placebo-controlled trial was performed on 29 patients (2015-2016) in the Imam Khomeini Hospital, Tehran, Iran (NCT02605213). Patients were divided into two groups by simple randomization method: placebo 11 (37.9%)/vancomycin 18 (62.1%) and were treated with oral vancomycin (125 mg, four times a day) for 12 weeks. All patients in both groups simultaneously underwent treatment with ursodeoxycholic acid (UDCA, 300 mg, three times a day) before and during the study. Patients’ laboratory data and clinical symptoms were recorded at the beginning, first and third month after starting treatment, and the response to treatment was analyzed. Results: 29 patients with a mean age of 36.27±10.60 years were included in the study. Primary endpoints were accomplished in the vancomycin group showing a significant decline in the mean level of PSC Mayo risk score (decrease rate 3rd month – baseline = -322.03%, p=0.026) during follow up time. Moreover, the analysis of the level of alkaline phosphatase (ALP) in the vancomycin group showed a significant decrease in the third month of treatment as compared to its level in the first month (mean difference 3rd month -1st month = -142.92, Decrease rate= -18.24%, p=0.02). Among secondary endpoints, erythrocyte sedimentation rate (p=0.005), gamma-glutamyl transpeptidase (p=0.02) and patients’ symptoms including fatigue, pruritus, diarrhea and anorexia showed a significant decrease in the vancomycin group. Conclusion: This study demonstrated an acceptable efficacy of vancomycin in the treatment of PSC. Abbreviations: BMI: body mass index ; ESR: Erythrocyte sedimentation rate; FIS-P: Fatigue Impact Scale- Persian; IBD: Inflammatory Bowel Disease; LSD: Least significant difference; PSC: Primary Sclerosing Cholangitis; RCT: Randomized, Controlled Trial; UDCA: Ursodeoxycholic acid; VAS: Visual Analogue Scale.

The imaging of hepatocellular carcinoma (HCC) is challenging and plays a crucial role in the diagnosis and staging of the disease. A variety of imaging modalities, such as ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) and nuclear medicine are currently used in evaluating patients with HCC. Although the best option for the treatment of these cases is hepatic resection or transplantation, only 20% of HCCs are surgically treatable. In those patients who are not eligible for surgical treatment, interventional therapies such as transcatheter arterial chemoembolization (TACE), percutaneous ethanol injection (PEI), radio-frequency ablation (RFA), percutaneous microwave coagulation therapy (PMC), laser ablation or cryoablation, and acetic acid injection are indicated. In this paper, we aimed to review the evidence regarding imaging modalities and therapeutic interventions of HCC.

BACKGROUND/AIMS: As a common gastrointestinal (GI) disorder, irritable bowel syndrome (IBS) has been reported to be associated with some psychological and neurological factors. This study aimed to evaluate the prevalence rate of restless legs syndrome (RLS) in a sample of IBS patients and to compare this prevalence with that of matched healthy controls. METHODS: This prospective comparative study was conducted in Tehran, Iran during 2010-2011. Based on the Rome III criteria, a total number of 225 definite IBS patients and 262 age- and sex-matched healthy controls were recruited in the final assessment to compare the prevalence rate of RLS between the 2 groups. RESULTS: RLS was significantly more frequent in IBS group (25.3% vs 6.5%, P < 0.001) which led to an odds ratio (OR) of 4.89 (95% CI, 2.75-8.70). IBS patients with co-morbid RLS significantly suffered more from stomach pain (96.5% vs 86.3%, OR = 4.36 [95% CI, 1.00-19.12]), nausea (40.4% vs 21.4%, OR = 2.48 [95% CI, 1.30-4.73]) and vomiting (10.5% vs 2.4%, OR = 4.82 [95% CI, 1.31-17.76]). CONCLUSIONS: By enrolling a considerable number of IBS patients and healthy controls, our study showed a significantly higher prevalence of RLS in IBS patients. Surprisingly, a higher prevalence rate of RLS was also accompanied with a more severe discomfort and stomach pain in IBS patients. It seems that screening patients with IBS for RLS may lead to greater identification of RLS and improved treatment for both conditions.

Context: Hepatitis C virus (HCV) infection is a major public health issue worldwide, including Iran. The new direct-acting antiviral agents (DAAs) with high efficacy have changed the landscape of HCV treatment. This guideline provides updated recommendations for clinical management of HCV infection in Iran. Evidence Acquisition: The recommendations of this guideline are based on international and national scientific evidences and consensus-based expert opinion. Scientific evidences were collected through a systematic review of studies that evaluated efficacy and safety of DAA regimens, using PubMed, Scopus and Web of Science. Expert opinion was based on the consensus of Iran Hepatitis Scientific Board (IHSB) in the 3rd national consensus on management of Hepatitis C in Iran, held on 22nd of July 2016. Results: Pegylated Interferon alpha (PegIFN), Ribavirin (RBV), Sofosbuvir (SOF), Ledipasvir (LDV) and Daclatasvir (DCV) are currently available in Iran. Pre-treatment assessments include HCV RNA level, HCV genotype and resistance testing, assessment of liver fibrosis, and underlying diseases. In HCV genotype 1 and 4, DCV/SOF and LDV/SOF are recommended. In HCV genotype 2, SOF plus RBV and in HCV genotype 3, DCV/SOF is recommended. Additional care for underlying diseases should be considered. Conclusions: Affordable new HCV treatment regimens are available in Iran, providing an opportunity for HCV elimination. Recommendations provided in this current national guideline can facilitate evidence-based management of HCV infection.

BACKGROUND This study is the first study to evaluate the nonadherence rate and reasons of same patient with inflammatory bowel disease (IBD) in Iran. METHODS During 9 months, 500 patients with IBD were enrolled in the study. Patients were interviewed about their nonadherence behaviors. Factor analysis was used to analyze the collected answers. RESULTS The overall rate of nonadherence was 33.3% (27.6% intentional nonadherence and 5.7% unintentional nonadherence). 33.6% of the patients had at least one relapse after discontinuing treatment. The most frequent reason for intentional nonadherence was discontinuing the treatment after recovering from symptoms (42.7%). The most frequent reason for unintentional nonadherence was forgetfulness (5.2%). 19.8% of the patients did not visit their gastroenterologist on time and they purchased drugs from the drugstore. These patients reported that their clinics were too far and difficult to access. There was no significant relationship between nonadherence and demographic variables. CONCLUSION Multiple reasons are suggested as factors of medication nonadherence and they seem to be different among different populations. Determining these possible reasons, could lead to finding suitable strategies to overcome or reduce them.

The rising concerns for future health burden of hepatitis C virus (HCV) in global scale has continuously encouraged preventing measures particularly public awareness programs. There is an increasing necessity for allocating HCV awareness issues in public scope, especially for high risk populations and patients. Proper knowledge of health care professionals and treating physicians and their attitude with regard to hepatitis C management is also crucial. Achieving this can be a constructive step forward in controlling and hopefully eradicating hepatitis C virus in our community. Having a clear scientific grasp on treatment options and protocols, the concept of “CURE” achievement in hepatitis C and the future hopes in enhancing virological response with the coming direct antiviral agents can significantly add to the current practices of treating hepatitis C. This scientific report paper outlines the insights communicated at the HCV symposium during the 4th Tehran Hepatitis Congress, November 2011, Tehran, Iran.

Background/Aims Irritable bowel syndrome (IBS) is a widespread chronic health condition which is significantly more prevalent in women. We conducted a gender difference analysis by comparing findings of men and women to determine whether any significant differences exist or not. Methods This single-center study was conducted in Tehran, Iran during 2009-2010. IBS was diagnosed on the basis of Rome III criteria. A simple "10 point" objective questionnaire was used. Results A total number of 144 IBS patients including 44 (30.6%) males and 100 (69.4%) females with the mean age of 37.50 ± 11.50 years, were assessed. The only differently observed symptom was nausea which was significantly more prevalent in females (49% vs 18.2%, P < 0.001). The commonest subtype of IBS in male patients was diarrhea predominant IBS (38.6%); while, constipation predominant IBS was the most frequent type among females (38%). Moreover, the frequency of loose, mushy or watery stools within the last 3 months was significantly higher among males (2.11 ± 1.67 vs 1.37 ± 1.50, P = 0.009). Conclusions We report that gender is important in IBS. Although qualitative comparison of different subtypes of IBS between male and female failed to meet the statistically significant level, the answers to the corresponding questions of ROME III IBS module suggest the higher prevalence of bowel movements and looser stool in males. Moreover, nausea was reported more often by females.

Hepatitis C remains as an important health problem worldwide. Hepatitis C treatment, especially among patients infected with HCV genotype 1 who are considered difficult to treat, is a high priority for health policy-makers. PegInterferon alfa instead of Interferon and ribavirin combination therapy has been accepted as the standard treatment regimen for hepatitis C patients; however, only 50% of patients infected with HCV genotype 1 achieve a sustained virological response. Published data from various clinical trials of protease inhibitors suggest that new therapeutic regimens may increase the chances of a successful response in patients infected with HCV genotype 1. Triple therapy that includes boceprevir has been shown to result in high rates of sustained virological response in both naive and experienced patients with HCV genotype 1 infection. In this review, we have summarized the results obtained with this new regimen and have attempted to provide a guideline for the treatment of patients in Iran, with emphasis on cost and the occurrence of adverse events. ARTICLE INFO

Some patients with non-alcoholic fatty liver disease have no obesity-related etiologies. Celiac disease could potentially present with elevated liver enzymes and chronic liver disease. The aim of this study was to evaluate the prevalence of celiac disease among patients with non-alcoholic fatty liver disease.Three hundred sixteen patients defined as non-alcoholic fatty liver disease based on elevated transaminases, liver ultrasound and/or liver biopsy were enrolled. Body mass index, waist circumference and symptoms were recorded. All were tested for recombinant IgA anti-tissue transglutaminase antibody and total IgA level. In patients with positive serology for anti-tissue transglutaminase, IgA class endomysial antibody values were determined with a commercially available indirect immunofluorescence method, and then endoscopy with duodenal biopsies was performed.The mean age of patients was 40.56±11.48 years and 50.9% were female. Celiac disease was confirmed in 7 patients (2.2%). Of these, all had body mass index between 18.37 and 26.91 kg/m². Celiac disease was more commonly diagnosed among non-alcoholic fatty liver disease patients with body mass index27 kg/m² compared to patients with body mass index27 kg/m² (5.83% vs. 0%; p=0.001).The prevalence of celiac disease among patients with non-alcoholic fatty liver disease is significantly higher than what was previously reported in the general population of Iran; thus, screening for celiac disease in these patients is reasonable, particularly in patients with body mass index27 kg/m².

Context Hepatitis C virus (HCV) infection is a major cause of liver-morbidity and mortality among patients with thalassemia. Peginterferon plus ribavirin is currently the recommended therapy for hepatitis C infection in patients do not have thalassemia, but using ribavirin in patients with thalassemia is restricted due to its hemolytic effect. To evaluate the efficacy and safety of adding ribavirin to peginterferon or interferon, authors performed a systematic review on the available literatures. Evidence Acquisition Trials were identified through electronic database, manual searches of journals and bibliographies and approaching authors of trials. Randomized trials that enrolled patients with a diagnosis of thalassemia and chronic hepatitis C infection treated with interferon or peginterferon with or without ribavirin were included. Two investigators independently evaluated the trials for inclusion criteria, risk of bias and data extraction. The primary outcomes were sustained virological response (SVR), liver-related morbidity, mortality and adverse events. The odds ratios from each trial were calculated individually and in the subgroup analysis of trials. Data were analyzed with fixed-effect model. Results Three randomized clinical trials with 92 patients were included. All three trials had unclear risk of bias. Compared with peginterferon monotherapy, adding ribavirin to peginterferon had significant beneficial effect on sustained virological response (OR = 3.44, 95% CI: 1.18 - 10.06). There was no significant difference between combination therapy and monotherapy in the end of treatment achievement response. Other than about 30% increase in blood transfusion due to anemia that returned to normal level 2 - 3 months after treatment, there was no significant increase in side effects followed by adding ribavirin to pegylated interferon (Peg-IFN). Data were insufficient to determine the impact of genotype, viral load and age on the response to treatment. Conclusions Compared with monotherapy, adding ribavirin to treatment is more effective in removing hepatitis C virus from the bloodstream in patients with thalassemia, it is also more effective in reducing the relapse rate after treatment. Except the increase in blood transfusion, there was no significant increase in side effects followed by adding ribavirin.

Background: Barrett’s oesophagus is a pre-malignant condition at gastroesophageal junction in which normal squamous epithelium is replaced by columnar shape epithelium, which predisposes oesophageal adenocarcinoma. It is known that Barrett’s oesophagus evolves as a consequence of chronic gastro-oesophageal reflux disease. Although progression of Barrett’s oesophagus to adenocarcinoma is still unclear, increasing incidence of oesophageal cancer and mortality worldwide make its study necessary. Several investigations have been made on the aetiology of oesophageal cancer. Most of them assessed genetical or environmental factors. However, potential role of bacteria in the development of oesophageal adenocarcinoma as a new environmental factor has not been addressed. Previous study on Barrett’s disease detected presence of Campylobacter concisus as a new emerging pathogen on Barrett’s and oesophageal cancer samples compared with healthy individuals. This indicates that this organism might involve in the progression of Barrett’s to oesophageal adenocarcinoma. Objectives: This study aimed to determine the effects of C. concisus on expression of three biomarkers including interleukin-18 (IL-18), tumour necrosis factor-α (TNF-α) and tumour suppressor gene (p53) in three Barrett's cell lines. Materials and Methods: Quantitative real-time PCR assays were developed to measure expression of pro-inflammatory mediators (IL-18 and TNF-α) and gene expression of p53 in Barrett's cell lines in co-culture with C. concisus. Results: The mentioned organism was able to modulate considerably expression of p53, TNF-α and IL-18 in a time-dependent manner. Conclusions: The results showed that microorganism influences expression of carcinogenesis biomarker and cytokines in cell line models and possibility promotes oesophageal adenocarcinoma.

Background Hemangioma, a congenital vascular malformation, is the most common benign liver lesion that is usually remain stable subsequently requiring not treatment; however, complications such as abdominal pain or fullness, coagulation disturbances, and inflammatory syndrome may occur, demanding a specific treatment of hemangioma. Objectives To assess the safety, feasibility and efficacy of trans-catheter arterial embolization (TAE) for the treatment of Liver hemangioma. Patients and methods TAE was performed on 20 patients with liver hemangioma. The embolic agent used was polyvinyl alcohol (PVA) particles (300-400 micron, Jonson and Johnson Cordis, USA). All patients were followed up for 6 months. Imaging was carried out and patients were also evaluated symptomatically through telephone interview by a physician. Results Twenty patients aged from 21 to 63 years (mean: 46.8, SD: 10.26) were included in this study. Post embolization syndrome, including abdominal pain, fever, and leukocytosis occurred in one patient 1 week after TAE and lasted for 3 days. No serious adverse event and TAE-related death was observed. None of the patient underwent another intervention including surgery. During follow up interval, decreased episode of abdominal pain was documented in all patients who had pain. Tumor enlargement was also stopped during the follow up. The average diameter of tumors was 97.00 mm (range: 25-200 SD: 47.85) and 88.95 mm (range: 23-195 SD: 43.27) before and after embolization, respectively. Comparison of images before and after TAE revealed statistically significant decrease in the size of lesion (P value: 0.004, t: 3.31). Conclusions Our findings indicate that TAE is a safe and efficient procedure for the treatment of liver hemangioma. Further studies with larger sample sizes are required to support therapeutic effects of TAE.

Barrett's oesophagus (BO) is a complicated condition at the gastroesophageal junction in which normal squamous epithelium is changed to columnar and leads to oesophageal adenocarcinoma (OA). In the past decades, the prevalence of Barrett's disease and mortality rate of adenocarcinoma has significantly increased throughout the word. Data has shown that molecular pathogenesis of disease has not been clearly identified. However, a wide-range and successful administration of probiotics in cancer and gastrointestinal diseases has lead to the investigation into the possible inhibitory role of probiotics in oesophageal cancer. This study was conducted to evaluate the inhibitory effect of probiotics on the expression of biomarkers in an in vitro model. Two different Barrett's oesophageal cell lines were selected to co-culture with B. longum and Lactobacillus acidophilus to measure expression of IL-18, TNFα, p53 (tumour suppressor gene), cyclooxygenase 2 and CDX1 (caudal type homeobox 1) genes. In addition, two different aspects of probiotic administration, therapeutic and prophylactic test were also examined. Results showed that micro-organisms could inhibit expression of biomarkers and therapeutic culture conditions were more effective than prophylactic tests. The results obtained suggest that it is possible to incorporate the administration of probiotics in BO and OA prevention.