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BackgroundIn patients with severe biliary pancreatitis, delayed cholecystectomy associated with a high risk of recurrence is recommended. The current study aimed to evaluate the effect of common bile duct (CBD) stenting on reducing gallstones migration and recurrence of symptoms in patients with pancreatitis and delayed cholecystectomy candidates.MethodsTo this purpose, the randomized, controlled clinical trial was performed on 40 patients with biliary pancreatitis who were candidates for delayed cholecystectomy. Patients were randomly divided into two groups of A and B that underwent CBD stenting after ERCP and received endoscopic treatment without stenting, respectively. A checklist recorded demographics and complications. Group A was followed up after four weeks to remove the stent and record the complications. Group B underwent MRCP to examine the migration of new gallstones as well as the complications.ResultsOf the 40 patients, 20 subjects (11 males and 9 females) were allocated to each group, matched for demographic variables. In the one-month follow-up, only one subject in group A manifested symptoms of gallstone migration and recurrence, while in group B, recurrence was observed in 6 patients (P = 0.037). There was no significant difference in the success rate of ERCP and the incidence of complications between the two groups.ConclusionCBD stenting in patients with biliary pancreatitis and gallstone could reduce the risk of recurrence and remigration of gallstones in delayed cholecystectomy cases.

Background The role of common bile duct (CBD) stenting in the establishment of bile stream in the elderly patients and the ones who are not good candidates for surgery due to not responding to treatments was well documented in previous studies. The current study aimed at investigating the effect of adding Ursodeoxycholic acid (UDCA) to CBD stenting alone in order to reduce the size of large and multiple CBD stones. Methods Clinical outcomes including success rates in CBD stones clearance, incidence of pancreatitis, perforation, bleeding, as well as, decrease in size of stones and liver enzymes after a two-month period were assessed in the UDCA + CBD stenting group. Results A total of 64 patients referring to Shahid Beheshti Hospital in Qom, Iran with multiple or large CBD stones (above three or larger than 15 mm) received standard endoscopic therapies and UDCA + CBD stenting (group B) and controls only received standard endoscopic therapies with only CBD stenting (group A). The mean reduction in the size of stones in group B was significantly higher than that of group A (3.22 ± 1.31 vs 4.09 ± 1.87 mm) (p = 0.034). There was no difference in the incidence rate of complications including pancreatitis, cholangitis, bleeding, and perforation between the two groups (P > 0.05). Conclusion Adding UDCA to CBD stenting, due to decrease in the stone size and subsequently facilitation of the stones outlet, can be considered as the first-line treatment for patients with large and multiple CBD stones. Also, in the cases with large or multi stones may be effective in reducing size and subsequently stone retrieval. Trial registry  The study protocol was approved by the Ethics Committee of Qom University of Medical Sciences (ethical code: IR.MUQ.REC.1397.075); the study was also registered in the Iranian Registry of Clinical Trials (No. IRCT20161205031252N8). This study adheres to CONSORT guidelines.

Background: Migraine is a common disorder which affects quality of life. There has been an increasing interest for discovering the association of gastrointestinal (GI) disorders with migraine during past years. This study aims to evaluate the association of Helicobacter pylori contamination, gastroesophageal reflux disease (GERD), gastric ulcer (GU), and duodenal ulcer (DU) with migraine in patients who underwent upper GI endoscopy due to refractory dyspepsia. Materials and Methods: In this observational cross-sectional study, 341 dyspeptic patients who underwent upper GI endoscopy in Shahid Beheshti Hospital, Qom, Iran, included during 2016-2018. A checklist was used for collecting demographics, symptoms, and results from endoscopy and H. pylori testing. Diagnosis of migraine was made according to the International Headache Society criteria in patients who had headache. Data were analyzed using Chi-square and independent samples t-tests in SPSS 16 (SPSS Inc., Chicago, IL, USA) withP < 0.05 as significance level. Results: Among 341 patients, 141 (% 41.3) were male and 200 (58.7%) were female. 149 (43.7%) patients were diagnosed with migraine, from which 48 (32.2%) were male and 101 (67.8%) were female. The observed difference in migraine prevalence among male and female was statistically significant (P = 0.003). 198 (58.06%) patients were H. pylori contaminated, among these 138 (69.7%) suffered from migraine. Among 143 H. pylori-negative patients, there were 11 (7.7%) migraineurs. The difference in the prevalence of migraine among H. pylori positive and negative patients was significant. H. pylori and GERD were associated with migraine withP < 0.001. Patients with DU were more commonly suffering from migraine (P = 0.001). The association in patients with GU was not statistically significant (P = 0.863). Conclusion: Migraine might be associated with GERD, H. pylori infection, and DU, and the treatment of the underlying GI disorder may control headaches.

Mesenteric ischemia is a rare disease with a high rate of mortality because of the non-specific symptoms which lead to delay in diagnosis and intervention. The main symptom is abdominal pain, which has a broad list of differential diagnoses. This study introduces a 17-year-old girl who presents to the emergency department with severe abdominal pain and hematemesis. Further evaluations revealed thrombosis in the mesenteric vein which leads to ischemia and gangrene of the small intestine. Her past medical history and drug history were negative, except she was taking levonorgestrel and cyproterone acetate for a 5 months period. Since long-term treatment with oral contraceptive pills, counts as a risk factor for venous thrombosis, this case seems to be uncommon. © 2019 Tehran University of Medical Sciences. All rights reserved. Acta Med Iran 2019;57(7):468-470.

A 52-year-old woman with a history of laparoscopic cholecystectomy within the past 2 weeks, presented to the emergency department with abdominal pain and icter from 2 days earlier. She complained of an epigastric pain with radiation to the back, which was aggravated after taking a meal and did not change with position.

Accumulation of free fluid in the peritoneal cavity is called ascites. The first step in identifying its etiology is to determine the serum-ascites albumin gradient (SAAG). According to this parameter, a high SAAG is regarded as a gradient greater than 1.1 g/dL. This condition has some differential diagnoses such as liver cirrhosis, Budd-Chiari syndrome, heart failure, and idiopathic portal fibrosis. In the present article, we present a young man with abdominal distention due to a high SAAG. Further evaluation of the abdominal and thoracic cavity revealed a mass in the posterior mediastinum, which had compressed the inferior vena cava and left atrium and led to Budd-Chiari syndrome. Evaluation of the biopsy sample showed fibrosarcoma. Mediastinal fibrosarcomas, though rare, should be considered in the differential diagnosis of mediastinal masses.

With respect to her clinical condition and a suspicious common bile duct (CBD) stone, magnetic resonance cholangiopancreatography (MRCP) was performed, which showed a dilated CBD with a diameter of 10 mm and a CBD stone with a diameter of 6 mm that was an indication for endoscopic retrograde cholangiopancreatography (ERCP) (figure 1). Presence of hepatic cirrhosis without coagulative disorder may not increase the probability of bleeding and administration of non-steroidal medicines plays no important role in the onset of bleeding.3,4 Precut sphincterotomy and papillary stenosis are independent risk factors.5 Moreover, zipper cut and needleknife sphincterotomy have been put forth as independent factors in a study carried out in Korea.6 Prevention of post ERCP bleeding includes identification of the patient's risk factors, being careful of the coagulative status of the patients, and accurate adoption of the proper ERCP methods. Middle East JDigDis 2019;11:??? Received: 10 Jan. 2019 Accepted: 20 Mar. 2019 * Corresponding Author: Faezeh Alemi, MD Gastroenterology and Hepatology Disease Research Center, Qom University of Medical Sciences, Shahid Beheshti Hospital, Qom, Iran Telefax: + 98 253 6122053 Email: faezeh.alemi@gmail.com REFERENCES 1.

Background: Migraine is a common disorder which affects quality of life. There has been an increasing interest for discovering the association of gastrointestinal (GI) disorders with migraine during past years. This study aims to evaluate the association of Helicobacter pylori contamination, gastroesophageal reflux disease (GERD), gastric ulcer (GU), and duodenal ulcer (DU) with migraine in patients who underwent upper GI endoscopy due to refractory dyspepsia. Materials and Methods: In this observational cross-sectional study, 341 dyspeptic patients who underwent upper GI endoscopy in Shahid Beheshti Hospital, Qom, Iran, included during 2016-2018. A checklist was used for collecting demographics, symptoms, and results from endoscopy and H. pylori testing. Diagnosis of migraine was made according to the International Headache Society criteria in patients who had headache. Data were analyzed using Chi-square and independent samples t-tests in SPSS 16 (SPSS Inc., Chicago, IL, USA) with P < 0.05 as significance level. Results: Among 341 patients, 141 (% 41.3) were male and 200 (58.7%) were female. 149 (43.7%) patients were diagnosed with migraine, from which 48 (32.2%) were male and 101 (67.8%) were female. The observed difference in migraine prevalence among male and female was statistically significant (P = 0.003). 198 (58.06%) patients were H. pylori contaminated, among these 138 (69.7%) suffered from migraine. Among 143 H. pylori-negative patients, there were 11 (7.7%) migraineurs. The difference in the prevalence of migraine among H. pylori positive and negative patients was significant. H. pylori and GERD were associated with migraine with P < 0.001. Patients with DU were more commonly suffering from migraine (P = 0.001). The association in patients with GU was not statistically significant (P = 0.863). Conclusion: Migraine might be associated with GERD, H. pylori infection, and DU, and the treatment of the underlying GI disorder may control headaches.

Liver cirrhosis is defined as the advanced stage of liver disease, which presents with loss of normal hepatic tissue and its replacement by fibrotic tissue. It leads to alteration in all liver functions including metabolic, synthetic, and coagulative function. Besides, accumulation of toxins may alter mental status. This pathogenesis alters the metabolism of many drugs, so that they should be used carefully or will need dose adjustment.1A necessity for anesthesia and surgery, for liver related or unrelated indications, is a challenging issue in the management of patients with cirrhosis. This would be the art of a gastroenterologist to assess the present situation of the patient and weigh the risks and benefits to help the anesthesiologist and the surgeon in making the best plan.2The final decision will be made upon the liver disease situation and the necessity and urgency of the surgical procedure. However, even in an acceptable anesthesiological and surgical risk background, considering some points before, during, and after the procedure is necessary to minimize the complications.

Objectives: This study was conducted to evaluate the efficacy of a combination therapy using aspirin (also known as acetylsalicylic acid (ASA)) and atorvastatin in comparison with atorvastatin alone to improve liver fibrosis and function in patients with cryptogenic cirrhosis. Methods: In this randomized double-blinded clinical trail, 40 patients with cryptogenic cirrhosis were randomly allocated to the intervention group (atorvastatin + ASA) and the control group (atorvastatin) treated for six months. Then liver function and stiffness (based on transient electrography) were compared. A checklist was used for data collection and the results were analyzed by SPSS 24 using chi-square test and paired t-test at the 0.05 significance level. Results: A total of 33 cases, including16 patients in group A (atorvastatin + ASA) and 17 in group B (atorvastatin + placebo) with a mean age of 50.3 ± 11.2 and 47.9 ± 10.6 years and BMI of 30.7 ± 4.2 and 30.8± 3.1 in groups A and B, were studied, respectively. Twelve patients (75%) in group A and 14 cases (82%) in group B were male. Both groups were homogenized in terms of demographic information at baseline. A significant improvement in Child score (P = 0.001 and P = 0.002 for groups A and B, respectively) and liver stiffness (P < 0.0001 and P = 0.007 for groups A and B, respectively) were observed in both groups after the intervention, however there was no significant improvement in child score (P = 0.982) and liver stiffness (P = 0.611) in comparing both groups. Conclusions: Although atorvastatin is effective in improvement of liver fibrosis and function in cryptogenic cirrhosis, adding ASA cannot improve its effects.