Tehran University Medical Journal

Background: Nasogastric tube (NG tube) usage was first described in 1921 by Levin. Surgeons routinely use NG tube in most esophageal resections. Considering the numerous complications caused by this tube, the uncertainty about its usefulness and the scarcity of studies conducted on the subject, particularly in esophageal cancer patients, we investigated the necessity of the NG tube in these cases.

Methods: This clinical trial was performed at the Cancer Institute of Imam Khomeini Hospital. Esophageal cancer patients were randomized into groups either with or without postoperative NG tube the latter group was also prescribed metoclopramide. Postoperative obstruction was the exclusion criteria. The operation was done by a team of surgeons using the surgical techniques of McKeown or Orringer. All patients received ranitidine, heparin and antibiotics postoperatively. All patients received postoperative chest X-ray and chest physiotherapy. The NG tube was inserted or reinserted for those with abdominal distention and/or repeated vomiting. The NG tube was pulled out after return of bowel movements. The variables recorded for each patient included the first day of flatus, the first day of defecation, the first day of bowel sound (BS) upon auscultation, duration of post-operative hospitalization, nausea and vomiting, abdominal distension, pulmonary complications, wound complications, anastomotic leakage and the need for placing/replacing the NG tube. Statistical analysis was performed using SPSS, v. 11.5.

Results: After randomization, the NG tube was inserted for 22 patients, and 18 patients had no NG tube. The incidence of anastomotic leakage was significantly higher in the NG-tube group. No significant differences between the two groups were found for other complications. The mean times until first passage of flatus, defecation and BS upon auscultation and the duration of post-operative hospitalization were not significantly different. The need for placing/replacing the NG tube was the same for both groups. There was no difference in the perioperative death rates between the two groups.

Conclusions: We conclude that the routine use of NG tubes after surgery is not recommended for all patients. NG tube should be used according to the specific needs of each patient. This protocol will protect patients from undesired complications.

Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: Stromal tumors of the gastrointestinal tract (GISTs) are uncommon and the cell of origin is actually mesenchymal. Stemming from smooth muscle, 90% of GISTs, or leiomyomas, are found in the lower two thirds of the esophagus. Typically solitary, multiple tumors (leiomyomatosis) are occasionally reported. Remaining intramural during their growth, most of their bulk protrudes toward the esophageal outer wall, with a freely-movable, normal-looking overlying mucosa. In this study, we report a rare case of esophageal leiomyomatosis treated by esophagectomy.
Case Report: A 70-year-old man presented with discomfort upon swallowing, dysphagia, nausea, belching and weight loss. After a barium swallow, only dilatation of the esophagus from the retained food and saliva was seen. CT scan revealed a 10-cm dilatation of the thoracic esophagus. An endoscopy and upper GI series was performed, but no pathology was found. Esophageal manometry and pH monitoring for gastroesophageal reflux were normal. Upon endoscopic ultrasonography, a thickening of the esophageal wall was identified 20-30 cm from the dental arch. The patient was diagnosed with a GIST, referred to surgeon and a transhiatal esophagectomy was performed. The patient was discharged from the hospital in good condition and has had no problem during the one-year period of follow up. 

Background: Obstructive gastrointestinal (GI) malformations are one of the most important congenital problems and have different clinical manifestations, which depend on the severity and location. Although, complete obstructive lesions cause classic intestinal obstructive symptoms in infants, incomplete obstruction might be asymptomatic until adulthood and sometimes cause unusual symptoms, which need extensive work up. Moreover, this delay could produce significant complications. Near all of these lesions are surgically correctable therefore awareness of this possibility is important in order to prompt appropriate management and referral plan.

Case report: In this report, we introduce five infants who had congenital GI malformations with different presentations such as vomiting, hematemesis, growth failure and steatorrhea. Appropriate time of diagnosis caused surgical correction of lesions except in one patient with very unusual presentation who was diagnosed late. As a result, in this case, severe growth and developmental delay appeared.

Conclusion: Congenital gastrointestinal obstruction has different manifestations. Awareness can help to survive patients.

Background: Thymidine phosphorylase (TP) catalyses the conversion of thymidine into thymine. Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is an autosomal recessive disease which is caused by mutations in the nuclear gene encoding TP, bringing about severe impairment of TP-enzyme specific activity and accumulation of thymidine in plasma. The clinical manifestations of MNGIE are recognizable and homogenous, but not in the early stages of the disease. In patients who are suspected of having MNGIE, determination of TP-specific activity in leukocytes and thymidine levels in plasma are diagnostic. The methods that are usually used for the measurement of TP activity and plasma thymidine are not rapid or accurate enough and lack sensitivity.

Methods: The specific activity of TP was measured by RP-HPLC in leukocytes of both the controls and the patients exhibiting clinical features suggestive of MNGIE. Moreover, plasma thymidine was assessed by the same method.

Results: The patients had detectable plasma thymidine (>3 µmol/L) but it was undetectable in the healthy controls. The patients' TP-specific activity decreased to less than 5% relative to the controls (14±4 nmol/h/mg vs. 525±165 nmol/h/mg, P<0.05). A diagnostic algorithm for the definitive diagnosis of MNGIE is suggestible based on the results of this study which relies on the measurement of plasma thymidine, TP-specific activity in leukocytes, or both.

Conclusion: In this study, we set up a sensitive and rapid assay for the evaluation of TP-specific activity by using RP-HPLC in Iran. In addition, we established reference values for TP-specific activity and plasma thymidine in the Iranian patients.

Clostridium difficile (C. difficile) is an important factor in the development of the gastrointestinal diseases because of irrational antibiotic prescription and antimicrobial resistance. In the past, this bacterium was introduced as an agent of the infection in the hospitals called "hospital acquired Clostridium difficile infection". This infection is a main cause of morbidity and mortality internationally. But changing in the epidemiology of the infection was observed in recent years. People not taking antibiotics as well as any contact with the clinical system were hospitalized due to the infection named "Community-Associated Clostridium difficile infection". Furthermore, the hypervirulent strains of C. difficile were identified outside of the health care facilities in different sources such as environment, animals and food products. Today the role of C. difficile has not been confirmed as a zoonotic agent or foodborne pathogen. Taking into account, it should be taken attention to the sensitive individuals such as pregnant women, elderly and children for the consumption of the contaminated food products with C. difficile spores and probable cause of the infection in these individuals. For this purpose, presentation of the guidelines or the prevention strategies for the transmission of bacteria in the society as well as the healthcare facilities is important. In this review study, the history, the risk factors of disease and the reports of infection in the healthcare facilities and outside of this environment in Iran were discussed. Finally, we supposed that based on the isolation of C. difficile with different genetic profile in Iran in comparison with international ribotypes, the existence of native strains leading to the infection in the community and the healthcare facilities is possible. This hypothesis shows the significance of regional differences in the epidemiology and microbiology of disease. In addition, according to the present reports on the irrational prescription of the antibiotics in our country, it seems that C. difficile infection is increasing but any continuous monitoring is not being occurred for the supervision in Iran. Approving these hypotheses need to the careful and continuous assessment besides comprehensive examination of molecular epidemiology of disease in the organizations related to the health in Iran.