A case of mediastinal fibrosis due to radiotherapy and 'downhill' esophageal varices: a rare cause of upper gastrointestinal bleeding.

'Downhill' varices are located in the proximal part of the esophagus. Their etiology differs from the distal types, with most of them usually being related to superior vena cava obstruction. Although bleeding due to 'downhill' varices is very rare, it can be life-threatening. Here, we present a case of upper gastrointestinal bleeding due to mediastinal fibrosis associated with chest radiotherapy for seminoma metastasis sixteen years previously, which was successfully treated conservatively.

The histological quality and adequacy of diminutive colorectal polyps resected using jumbo versus hot biopsy forceps.

BACKGROUND: Polypectomy with jumbo forceps (JF) and polypectomy with hot biopsy forceps (HBF) are still widely used techniques for removal of diminutive colorectal polyps (DCPs). JF may be more effective for the removal of DCPs because of their larger size. AIM: To evaluate the histological quality and adequacy of DCPs resected using JF compared with HBF. METHODS: One hundred and seventy-nine patients with 237 DCPs were included in this study. DCPs were removed using either JP or HBF. RESULTS: The tissue architecture was good in 29.9 % of the HBF group, in comparison with 90 % of the JF group (p < 0.001). No cautery damage or crash artifact was observed in 93.3 % of JF group and in 8.5 % of HBF group (p < 0.001). Moreover, there were statistically significant differences between the groups with regard to the high level of cautery damage or crush artifact (p < 0.001). The overall diagnostic quality of the specimens removed using JF was significantly better than that of the specimens removed by HBF (96 vs. 80 %, respectively, p < 0.001). There were statistically significant inverse associations between cautery damage or crush artifact and overall diagnostic quality of HBF and JF (r = -0.373, p < 0.001; r = -0.382, p < 0.001, respectively). Surgical margins were determined as negative in 87.5 % of the JF group and in 76.1 % of the HBF group (p = 0.022). A total of 80.8 % of the JF specimens and 30.8 % of the HBF specimens were well evaluated for two lateral and deep surgical margins (p < 0.001). CONCLUSION: JF was superior to HBF for histopathological interpretation and eradication of DCPs.

Clinical importance of celiac disease in patients with recurrent aphthous stomatitis.

BACKGROUND/AIMS: Recurrent aphthous stomatitis is a common disease of the oral mucosa that is characterized by recurrent, painful ulcers of unknown etiology. The association between celiac disease and recurrent aphthous stomatitis has been evaluated in several studies, but variable results have been reported. The purpose of this study was to determine the prevalence of celiac disease in patients with recurrent aphthous stomatitis. METHODS: The study group consisted of 82 patients, all of whom had a history of recurrent aphthous stomatitis. The control group included 82 patients who did not have aphthous stomatitis. Patients were screened for IgA anti-endomysial antibodies, IgG anti-endomysial antibodies, IgA anti-gliadin antibodies, and IgG anti-gliadin antibodies. Patients with positive serology underwent endoscopic biopsies of the duodenal mucosa. Patients in both groups were also questioned regarding gastrointestinal symptoms. RESULTS: One patient (1.2%) out of 82 in the study group was diagnosed with celiac disease by biopsy. Gastroesophageal reflux disease symptoms, heartburn and regurgitation were determined to be of higher incidence in the study group (p<0.001 and p<0.001, respectively). None of the 82 patients in the control group were diagnosed as having celiac disease. CONCLUSION: It is concluded that there is no apparent etiological link between recurrent aphthous stomatitis and celiac disease and that screening recurrent aphthous stomatitis patients for celiac disease has little clinical value. Additionally, regurgitation of gastric acid to the oral cavity may precipitate the formation of aphthous stomatitis.

Efficacy of probiotics in Helicobacter pylori eradication therapy.

BACKGROUND/AIMS: Triple therapy with a proton pump inhibitor, amoxicillin and clarithromycin in Helicobacter pylori eradication is widely accepted, but this combination fails in a considerable number of cases. Our aim was to evaluate whether probiotic-containing yogurt affects the success of eradication. The second aim was to investigate the efficacy of probiotics in the prevention of the side effects related to eradication therapy. METHODS: A total of 76 histopathologically proven H. pylori-positive patients enrolled in this study were randomized into two groups. The following regimens were recommended: Group A: pantoprazole (40 mg, b.i.d.), amoxicillin (1000 mg b.i.d.), clarithromycin (500 mg b.i.d.), and 125 ml of probiotic-containing yogurt (Bifidobacterium DN-173 010-1010 cfu/g) before breakfast for 14 days; and Group B: pantoprazole (40 mg, b.i.d.), amoxicillin (1000 mg b.i.d.) and clarithromycin (500 mg b.i.d.) for 14 days. Subjects were asked to report any side effects of therapy during the treatment period. H. pylori status was rechecked four weeks after the completion of the eradication therapy by 13C-urea breath test. RESULTS: H. pylori eradication was achieved in 25 of the 38 patients in Group A (66%) and in 20 of the 38 patients (53%) in Group B. Although the success rate was higher in Group A than in Group B, the difference was not significant (p=0.350). The addition of probiotics to the triple therapy significantly lessened the frequency of stomatitis and constipation (p=0.037 and p=0.046, respectively). CONCLUSIONS: The addition of probiotic-containing yogurt to the triple therapy did not increase the H. pylori eradication rates for the evaluated dosage and model; however, it decreased the frequency of stomatitis and constipation.

Effect of the mucolytic erdosteine on the success rate of PPI-based first-line triple therapy for Helicobacter pylori eradication: a prospective, double-blind, randomized, placebo-controlled study.

OBJECTIVE: Because Helicobacter pylori creates a well-sheltered microenvironment within the gastric mucus layer, it has been speculated that the disruption of this space by a mucolytic agent may enhance the eradication rate. The aim of the present study was to investigate the effect of erdosteine, a strong mucolytic agent, on the effectiveness of PPI-based, first-line triple therapy in the eradication of H. pylori. MATERIAL AND METHODS: Initially, 196 patients were enrolled to the study. Of these, 79 H. pylori-positive patients were randomized to the erdosteine group (triple therapy consisting of pantoprazole, amoxicillin and clarithromycin plus erdosteine; n = 40) or the placebo group (triple therapy plus placebo; n = 39) for 14 days. Endoscopic biopsies and (13)C-urea breath tests were performed at entry and at 4-6 weeks after the completion of the treatment. Additionally, rapid urease tests were performed at entry. RESULTS: The eradication of H. pylori was achieved in 30 (75%) of the 40 patients in the erdosteine group and in 20 (51.3%) of the 39 patients in the placebo group, according to the ITT analysis (p = 0.028). When the PP analysis was performed as well, H. pylori eradication was achieved in 30 (78.9%) of the 38 patients in the erdosteine group and in 20 (52.6%) of the 38 patients in the placebo group (p = 0.016). CONCLUSIONS: Erdosteine is an efficient adjuvant therapy that could be used in conjunction with first-line triple therapy in the treatment of H. pylori.

Administration of olive oil followed by a low volume of polyethylene glycol-electrolyte lavage solution improves patient satisfaction with right-side colonic cleansing over administration of the conventional volume of polyethylene glycol-electrolyte lavage solution for colonoscopy preparation.

BACKGROUND: Proper bowel cleansing before colonoscopy is essential for satisfactory evaluation of the colon. The required consumption of a large volume of salty-tasting liquid, 4 L of polyethylene glycol-electrolyte lavage solution (PEG-ELS), is the primary limitation to achieving this goal. OBJECTIVE: To achieve better patient satisfaction with efficient bowel cleansing, we compared the effects of the conventional volume (4 L) of PEG-ELS with those of a low volume (2 L) in combination with pretreatment using different laxatives, such as magnesium hydroxide (milk of magnesia) and olive oil. DESIGN: Randomized, controlled study. SETTING: A single research hospital. PATIENTS: Patients undergoing elective colonoscopy. INTERVENTIONS: A total of 120 patients were randomized to 1 of 3 different preparation regimens: 39 patients were prepared with a conventional volume (4 L) of PEG-ELS (Preparation [Prep] 1), and the remaining patients were prepared with a lower volume (2 L) of PEG-ELS and pretreatment with a laxative, either 15 g of magnesium hydroxide (40 patients, Prep 2) or 60 mL of olive oil (41 patients, Prep 3) 3 hours before PEG-ELS administration. MAIN OUTCOME MEASUREMENTS: The primary outcome was the efficacy of colonic cleansing on the left and right sides. Secondary outcomes were patient satisfaction and side effects. RESULTS: The olive oil regimen (Prep 3) resulted in significantly more adequate bowel cleansing of the right colon than administration of the conventional volume of PEG-ELS (Prep 1) and the magnesium hydroxide (Prep 2) regimen (97.6% vs 74.5% and 72.5%, respectively, P = .007). However, this difference was not observed in the left colon (91.5%, 85.5%, and 91.8% for Preps 1, 2, and 3, respectively, P = .776). When asked, 38 patients (95%) taking Prep 2, 35 patients (85.3%) taking Prep 3, and only 11 patients (28.2%) taking Prep 1 preferred the same preparation regimen if they required a future colonoscopy (P =.006), based on ease of use and taste. The side effects were comparable in each group. LIMITATIONS: The limitations of this study include the relatively small sample size, the single-center study design, and the use of a nonvalidated symptom scoring system. CONCLUSION: Pretreatment with olive oil before administration of a low volume of PEG-ELS enhances both patient satisfaction and the quality of right-side colonic cleansing over the administration of the conventional volume of PEG-ELS for colonoscopy preparation. Although the magnesium hydroxide regimen (Prep 2) was the preferred regimen in this study, its colonic cleansing effectiveness was not as great as those of the other regimens. Based on our results, the olive oil regimen is recommended, especially for patients who are not able to consume large volumes of liquids, such as the elderly, and those who are suspected of having subtle right-side colonic lesions.

Serum copper, ceruloplasmin and 24-h urine copper evaluations in celiac patients.

The aim of the study is to evaluate the serum copper, ceruloplasmin and 24-h urine copper levels in celiac patients. Serum copper, ceruloplasmin and 24-h urine measurements were evaluated in patients with celiac (n = 32), Crohn's (n = 25), Wilson's (n = 11) and in a healthy group (n = 35). Serum and 24-h urine zinc levels, AST, ALT, BUN, creatinine, iron, hemoglobin, hematocrit, lymphocyte, sedimentation and CRP levels were also measured. Results were evaluated statistically and significance was accepted as meaningful if P < 0.05. In celiacs, levels of urine copper were high (52 +/- 29 microg/day, P < 0.000) but serum copper was the same as in controls (105 +/- 16 microg/dl, P < 0.158). High urinary copper of celiacs were coming out in women (56 +/- 30 microg/day) and in man (33 +/- 17 microg/day, P < 0.115). Most celiacs were female (P < 0.001). Serum copper and ceruloplasmin levels in all groups were higher in women than in men and this was meaningful for serum copper in the control group (P < 0.045) and for ceruloplasmin in Crohn's (P < 0.055) and control groups (P < 0.031). Serum (70 +/- 14 microg/dl, P < 0.000) and urine zinc levels (25 +/- 15 microg/dl, P < 0.039) of celiacs were low. Ceruloplasmin levels were higher in celiacs (337 +/- 64 U/1) and Crohn's patients (366 +/- 47 U/l, P < 0.000). Correlations observed in the groups of celiac (P < 0.029) and Crohn's (P < 0.024), celiac and Wilson's (P < 0.001) and Crohn's and Wilson's (P < 0.001) between the ceruloplasmin and 24-h urine copper parameters. AST and ALT levels were higher in celiac and Wilson's patients than in Crohn's patients and controls. Mean CRP levels were significantly higher in Crohn's than others. Lymphocyte counts were meaningfully higher in celiacs. Statistically, while mean iron, hemoglobulin and hematocrit levels of celiac and Crohn groups were meaningfully lower than the normal and Wilson's group, it was similar in Wilson's and the control group. Serum copper (85 +/- 26 microg/dl, P < 0.158) and ceruloplasmin (219 +/- 83 U/l, P < 0.001) levels were low and 24-h urine copper levels were high (415 +/- 346 microg/day) in Wilson's group. Increased urinary loss may be another cause of copper deficiency in female celiacs besides malabsorption and this topic needs more investigation. Increased urinary copper levels in celiac women should not always be regarded as a diagnosis of Wilson's disease.

The effectiveness of lamivudine treatment in cirrhotic patients with HBV precore mutations: a prospective, open-label study.

In this study, the effect of lamivudine therapy on viral suppression, Child-Pugh score, and survival was assessed in patients with decompensated cirrhosis due to precore mutant hepatitis B virus and the results were compared with those for nonreplicative cirrhotic patients. Twenty-three replicative patients who received lamivudine and 15 nonreplicative patients were included and followed up for an average of 23.7+/-13.4 months. At baseline, there were no significant differences between the groups with regard to clinical and biochemical parameters or Child-Pugh scores, except for serum alanine aminotransferase levels (P<0.05) and quantitative hepatitis B virus DNA measurements (P<0.001). Compared to baseline, there was no significant difference in Child-Pugh score in the lamivudine group at the last visit (P=0.202), whereas a marked increase was observed in nonreplicative patients (P=0.002). Mortality rates in the lamivudine and nonreplicative groups were 17.43% and 13.3%, respectively (P=0.556), and there was no difference in survival analysis (P=0.809). Lamivudine therapy stabilizing clinical situation in decompensated cirrhotics with precore mutation makes the natural history of the disease equal with nonreplicative decompensated cirrhotics or even provides some advantages over them.

Cobalamine deficiency associated with neuropathy and oral mucosal melanosis in untreated gluten-sensitive enteropathy.

A 32-year-old woman was admitted with complaints of difficulty in walking and hypoaesthesia and tingling in her legs. She had short stature and brown-black hyperpigmentation, cheliosis, dental irregularities and scars in the axillary regions. Neurological examination revealed mild, symmetric, predominantly distal weakness of the legs; deep tendon reflexes were depressed. There was glove-and-stocking decrease in pinprick and temperature perception but proprioception and light touch were normal. Investigations established a diagnosis of celiac disease; her neurological features improved on gluten-free diet, but oral pigmentation persisted.

A case of Budd-Chiari syndrome secondary to multiple thrombogenic conditions: a case report and review of literature.

This report describes a case of Budd-Chiari syndrome caused by latent polycythemia vera and factor V Leiden mutation. This syndrome usually occurs due to thrombosis of hepatic veins or membranous obstruction of inferior vena cava. The most common reasons for thrombosis are manifest polycythemia vera and the other prothrombotic conditions. Recently, latent polycythemia vera and factor V Leiden mutation have been reported in increasing frequency. In this report, we aimed to emphasize that all prothrombotic conditions must be evaluated while investigating the etiology of Budd-Chiari syndrome, including latent polycythemia vera and factor V Leiden mutation, and appropriate antithrombotic and surgical therapies must be performed without delay.

Malposition of internal organs: a case of situs ambiguous anomaly in an adult.

Situs ambiguous anomaly is a rarely encountered condition in clinical practice that is characterized by the presence of multiple congenital anomalies relevant to intraabdominal organs and the cardiovascular system. While this syndrome is mostly diagnosed as a serious cyanotic cardiac disease in the first year of life, only 5% may survive beyond five years of life, and it can be a diagnostic challenge. In this report, we present an adult case of situs ambiguous anomaly which was diagnosed incidentally. The patient had centrally located liver, multiple splenules, interrupted inferior vena cava with azygos continuation, and bilateral bilobed lungs. Furthermore, she had a history of an atrial septal defect operation 20 years previously. These congenital anomalies were found to be compatible with situs ambiguous anomaly (its polysplenia variant). The interesting points of this patient are that she reached an advanced age without complaint in spite of congenital heart disease, and that the diagnosis was made incidentally during routine examination.