Is Post COVID-19 cholangiopathy an appropriate indication for liver transplantation?

The effect of severe acute respiratory syndrome coronavirus-2, which has infected more than 765 million people in the world to date, has decreased gradually, but the effect of late complications after the disease has begun to increase. Post-coronavirus disease 2019 cholangiopathy can be considered as one of the late complications identified in patients recovering from SARS-CoV-2 infection. A 38-year-old man was admitted to our emergency department with fever up to 39,5ºC, dry cough, anosmia, and dyspnea for 4 days. In the chest computed tomography, extensive opacity areas were compatible with multifocal pneumonia. A throat swab confirmed SARS-CoV-2 infection. The patient was treated in the intensive care unit with mechanical ventilator support during 4 weeks. A significant increase in cholestasis enzymes was observed in the patient's control blood. The results of Magnetic Resonance Cholangiopancreatography, Endoscopic Retrograde Cholangio Pancreatography and liver biopsy performed for the etiology of the patient were compatible with post-COVID-19 cholangiopathy. Liver transplantation from a living donor was performed in the patient whose cholangiopathy continued in the first year of follow-up. The patient's clinical course was positive after liver transplantation. It emphasizes that despite the improvement in the lung involvement of COVID-19, the virus can cause long-term liver damage. Liver transplantation may sometimes be required in the treatment of post-COVID-19 cholangiopathy, as in our patient. The persistence of the patient's liver disease for approximately 1 year after Covid-19 and its positive course after liver transplantation show that post-COVID-19 cholangiopathy is a suitable indication for transplantation. The persistence of elevated cholestasis enzymes and bilirubin values after recovery from COVID-19 may help identify patients with post-COVID-19 cholangiopathy in the early period. Early recognition of the occurrence of post-COVID-19 cholangiopathy is important to decide the appropriate course of action.

Association between disease activity and ischaemia-modified albumin in patients with ulcerative colitis.

Introduction: An increased level of ischaemia-modified albumin (IMA) is not specific for cardiac ischaemia and has been shown to be elevated in many other conditions causing oxidative stress. Aim: To assess the association between IMA and the disease activity in ulcerative colitis (UC), in which oxidative stress is thought to play a role in its pathogenesis. Material and methods: A total of 57 patients with ulcerative colitis (30 with active disease and 27 in remission) and 29 healthy controls were included in the study. IMA levels in those with active disease, those in remission, and healthy controls were compared. The correlations between IMA and other acute phase reactants were also assessed in the patient group. Results: Significantly higher levels of IMA were found in patients with active UC as compared to those in remission and controls (p < 0.001). Patients in remission and control subjects did not differ significantly in terms of IMA levels. Also, IMA correlated with C-reactive protein and erythrocyte sedimentation rate, while it did not correlate with white blood cell count and platelet count. Conclusions: Our results suggest that IMA, a marker of oxidative stress, may be a useful parameter for assessing the disease activity in patients with ulcerative colitis.

Radial EUS Examination Can be Helpful in Predicting the Severity of Acute Biliary Pancreatitis.

We investigated the utility of noncontrast enhanced endosonography (EUS) in predicting the severity of acute pancreatitis (AP) during the first 72 to 96 h of admission.In total, 187 patients with acute biliary pancreatitis were included. The patients were classified into 2 groups as having severe and mild AP according to the Modified Glasgow scoring and computerized tomography severity index (SI). The 158 cases with mild and 29 cases with severe AP had a similar age and sex distribution.Although none of the cases with mild AP developed morbidity and death, of the cases with severe AP, 16 developed serious morbidities and 5 died. On EUS examination, we looked for parenchymal findings, peripancreatic inflammatory signs, free or loculated fluid collections, and abnormalities of the common bile duct and the pancreatic channel. Statistical analysis indicated a significant relationship between the severity of AP with diffuse parenchymal edema, periparenchymal plastering, and/or diffuse retroperitoneal free fluid accumulation, and peri-pancreatic edema. We also defined an EUSSI and found that the EUSSI had sensitivity of 89.7%, specificity of 84.2%, positive predictivity value (PPV) of 88.9%, negative predictivity value (NPV) of 91.2%, and an accuracy of 87.9% in the differentiation of mild and severe AP. We found that the EUSSI had an accuracy of 72.4%, sensitivity of 75.4%, specificity of 65.1%, PPV of 69.3%, and NPV of 73.1% for determining mortality.Our data suggest that EUS allowed us to accurately predict the severity and mortality in nearly 90% of cases with AP.

Assessing the Effect of Leptin on Liver Damage in Case of Hepatic Injury Associated with Paracetamol Poisoning.

Background Aim. In case of high-dose acetaminophen intake, the active metabolite can not bind to the glutathione, thereby inducing cellular necrosis through binding to the cytosol proteins. This trial was performed to histologically and biochemically investigate whether leptin was protective against liver damage induced by paracetamol at toxic doses. Material and Method. In our trial, 30 female rats, divided into 5 groups, were used. IP leptin administration was performed after an hour in the group of rats, in which paracetamol poisoning was induced. The groups were as follows: Group 1: the control group, Group 2: 20 µg/kg leptin, Group 3: 2 g/kg paracetamol, Group 4: 2 g/kg paracetamol + 10 µg/kg leptin, and Group 5: 2 g/kg paracetamol + 20 µg/kg leptin. Results. The most significant increase was observed in the PARA 2 g/kg group, while the best improvement among the treatment groups occurred in the PARA 2 g/kg + LEP 10 µg/kg group (p < 0.05). While the most significant glutathione (GSH) reduction was observed in the PARA 2 g/kg group, the best improvement was in the PARA 2 g/kg + LEP 10 µg/kg group (p < 0.05). Conclusion. Liver damage occurring upon paracetamol poisoning manifests with hepatocyte breakdown occurring as a result of inflammation and oxidative stress. Leptin can prevent this damage thanks to its antioxidant and anti-inflammatory efficacy.

Can red cell distribution width be a marker of disease activity in ulcerative colitis?

AIM: The current study aimed to investigate the association between disease activity and red cell distribution width (RDW) levels in ulcerative colitis and to determine whether RDW can be used as a marker of disease activity in non-anemic ulcerative colitis. METHODS: The RDW levels of 310 ulcerative colitis patients who underwent colonoscopy were analyzed retrospectively. The patients were divided into two groups (active disease and remission) according to the endoscopic activity index. In addition, the accuracy of RDW in determining disease activity in non-anemic patients was assessed. The efficacy of RDW in determining disease activity was compared to that of white blood cell count, platelet count, C-reactive protein, and erythrocyte sedimentation rate. RESULTS: Two hundred and six (66.5%) patients had active disease, and 104 (33.5%) were in remission. The mean RDW levels in patients with active ulcerative colitis and in those in remission were 16.8±2.9 and 15.5±1.4, respectively (P<0.001). Ninety-six (46.6%) patients in the active disease group and 89 (85.6%) in the remission group were non-anemic, and their respective RDW levels were 15.4±1.2 and 15.3±1.1 (P=0.267). The sensitivity and specificity of RDW in determining inflammation were 41% and 91%, respectively (AUC 0.65, P<0.001). CONCLUSIONS: This study demonstrated that RDW can be used as a marker for disease activity in ulcerative colitis, but it did not have the same efficacy in the non-anemic group.

Gastric polyps and polypoid lesions: Retrospective analysis of 36650 endoscopic procedures in 29940 patients.

BACKGROUND/AIMS: The frequency of gastric polyps increases with the widespread use of endoscopy for diagnosis and treatment. As gastric polyps can be malignant or premalignant, histopathological evaluation is needed. The aim of this study is to determine the prevalence and characteristics of gastric polyps in patients undergoing endoscopy. MATERIALS AND METHODS: This study consisted of a retrospective analysis of 36650 consecutive endoscopy and associated pathology reports of 29940 patients between December 2005 and February 2012 in a tertiary-referral center. RESULTS: Gastric polypoid lesions were detected in 666 (2.22%) patients. Hyperplastic polyps were the most common type of polyps (36.2%), followed by fundic gland polyps (8.3%), inflammatory fibroid polyps (2.4%) and adenomatous polyps (1.9%). Foveolar hyperplasia, neuroendocrine tumor, xanthoma, gastrointestinal stromal tumor, adenocarcinoma and lymphoma were less commonly seen. Malignant transformation was seen in 0.42% of hyperplastic polyps and in 23.1% of adenomatous polyps. CONCLUSION: Endoscopic appearance of gastric polyps can be variable, distinguishing macroscopically can be misleading. Because of their malignant potential histopathological evaluation is mandatory and polypectomy should be performed whenever possible.

The effect of intravenous iron treatment on quality of life in inflammatory bowel disease patients with nonanemic iron deficiency.

Background. Iron deficiency is the prevalent complication of inflammatory bowel disease (IBD). Herein, we investigated the effect of intravenous iron treatment on quality of life (QoL) in nonanemic and iron deficient IBD patients. Methods. Eighty-five IBD patients were recruited for this study. The patients were intravenously administered 500 mg iron sucrose in the first week of the study. Hematologic parameters and QoL were evaluated before to iron treatment and during the 12th week of treatment. The Inflammatory Bowel Disease Questionnaire (IBDQ) and the Short Form-36 (SF-36) Health Survey were used to assess QoL. Results. Prior to intravenous iron administration, the IBDQ, SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were 152.3 ± 30.6, 46.7 ± 7.3, and 45.7 ± 9.8, respectively. In the 12th week of iron administration, those scores were 162.3 ± 25.5 (P < 0.001), 49.3 ± 6.4 (P < 0.001), and 47.6 ± 8.9 (P = 0.024), respectively, which were all significantly different from the scores prior to iron administration. The mean changes in the IBDQ scores for ulcerative colitis and Crohn's disease were 8.7% and 3.0% (P = 0.029), were 6.4% and 4.7% (P = 0.562) for the SF-36 PCS, and were 4.6% and 3.2% (P = 0.482) for the SF-36 MCS, respectively. Conclusion. Intravenous iron treatment may improve QoL in nonanemic, but iron deficient, IBD patients.

An Evaluation of the Correlation between Hepcidin Serum Levels and Disease Activity in Inflammatory Bowel Disease.

Aim. While there are many well-defined serological markers for inflammatory bowel disease (IBD), there is limited evidence that they positively affect clinical outcomes. This study aimed to evaluate the correlation between hepcidin serum levels and disease activity in IBD. Materials and Methods. Eighty-five consecutive IBD patients were enrolled in the study. Hepcidin serum levels were assessed using an enzyme-linked immunosorbent assay (ELISA) and were compared with disease activity as well as the interleukin-6 (IL-6) and C-reactive protein (CRP) levels. Results. The mean hepcidin serum levels in Crohn's disease (CD) patients in remission and in the active phase were 3837 ± 1436 and 3752 ± 1274 pg/mL, respectively (P = 0.613). The mean hepcidin serum levels in ulcerative colitis (UC) patients in remission and in the active phase were 4285 ± 8623 and 3727 ± 1176 pg/mL, respectively (P = 0.241). Correlation analysis between inflammatory markers and hepcidin serum levels indicated that there was no correlation between hepcidin levels and IL-6 (P = 0.582) or CRP (P = 0.783). Conclusion. As an acute-phase protein, hepcidin seems to have a lower efficacy than other parameters in the detection of activation in IBD.

Assessment of presence and grade of activity in ileal Crohn's disease.

BACKGROUND/AIMS: To assess the sensitivity of magnetic resonance enterography (MRE) in the diagnosis of Crohn's disease (CD) activity and correlation between endoscopic and MRE scores in predicting the activity grade. MATERIALS AND METHODS: Twenty-five ileal CD patients with clinical and biochemical evidence of activation underwent ileocolonoscopy and MRE within 7 days of their application. Simplified endoscopic scoring of CD (SES-CD) and MRE scores was done and compared with each other and other parameters of activation (CRP, leukocyte count, platelet count). RESULTS: The sensitivity of MRE scoring was found to be 92%; however, the statistical correlation with SES-CD was not significant (p=0.83) for the grading of the activity. CONCLUSION: MRE scoring is sensitive enough to use in CD activity evaluation; however, it can not be used alone, and it is rather a complementary technique to endoscopy and is especially valuable for patients with extraluminal disease.

Clinical utility of hepatitis B surface antigen levels during the natural history and treatment of chronic hepatitis B infection.

INTRODUCTION: Hepatitis B surface antigen (HBsAg) level quantitation may be helpful for understanding the natural history of the disease and its response to treatment. AIM: To determine the serum HBsAg levels during the different phases of chronic hepatitis B (CHB) infection and HBsAg levels of patients who are on treatment with oral antiviral drugs. MATERIAL AND METHODS: PATIENTS WERE CATEGORIZED IN FOUR GROUPS: 9 patients in the immune clearance (IC) phase, 46 patients in the inactive carrier (INC) phase, 25 patients in the reactivated HBeAg negative disease (END) phase and 60 HBeAg negative patients who were on treatment with oral antiviral drugs. HBsAg levels were compared between all groups. HBsAg and HBV DNA levels were compared in three phases of HBV infection. Patients on treatment were divided into two groups, taking lamivudine (L) and taking tenofovir (T). HBsAg levels were compared between END, L and T groups. RESULTS: The HBsAg levels were different between each phase of CHB (p < 0.0001). HBsAg levels were highest in the IC phase and lowest in the INC phase. The HBsAg/HBV DNA ratio was significantly higher in the INC phase than the END and IC phases (p < 0.0001). HBsAg levels were higher in the END phase than the INC phase (p < 0.0001) and higher than the treatment group (p = 0.007). The HBsAg levels had a good correlation with HBV DNA in the natural course of CHB (r = 0.72, p < 0.0001). HBsAg levels were higher in the END group than the L and T groups (p < 0.05). HBsAg levels were higher in the L than the T group (p < 0.05). CONCLUSIONS: This study demonstrates that HBsAg levels vary during the natural history of chronic hepatitis B infection. Also, the monitoring of HBsAg levels may help us to determine the best management strategy and to decide future treatment algorithms.

Evaluation of the effectiveness of endoscopic retrograde cholangiopancreatography in patients with perihilar cholangiocarcinoma and its effect on development of cholangitis.

Objective. We aimed to determine the effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) in patients with inoperable perihilar cholangiocarcinoma and establish the incidence of cholangitis development following ERCP. Material and Method. This retrospective study enrolled patients diagnosed with inoperable perihilar cholangiocarcinoma who underwent endoscopic drainage (stenting) with ERCP. Patients were evaluated for development of cholangitis and the effectiveness of ERCP. The procedure was considered successful if bilirubin level fell more than 50% within 7 days after ERCP. Results. Post-ERCP cholangitis developed in 40.7% of patients. Cholangitis development was observed among 39.4% of patients with effective ERCP and in 60.6% of patients with ineffective ERCP. Development of cholangitis was significantly more common in the group with ineffective ERCP compared to the effective ERCP group (P = 0.001). The average number of ERCP procedures was 2.33 ± 0.89 among patients developing cholangitis and 1.79 ± 0.97 in patients without cholangitis. The number of ERCP procedures was found to be significantly higher among patients developing cholangitis compared to those without cholangitis (P = 0.012). Conclusion. ERCP may not provide adequate biliary drainage in some of the patients with perihilar cholangiocarcinoma and also it is a procedure associated an increased risk of cholangitis.

Malignancy risk of gastric ulcers: could it be higher than the expected values?

There are many reported methods in the literature for the discrimination between malignant and benign gastric ulcers by endoscopic evaluation, but unfortunately this could not be done in 20% of the cases. The sensitivity for diagnosis of malignant ulcers increases by multiple biopsies and endoscopies. In this study, solitary gastric ulcers which were detected at 1680 gastroscopies between January 2001 and June 2002 are evaluated. The ulcers which were on gastric mass, multiple little aphthous ulcers and ulcers with hemorrhagic erosions having a diameter less than 0.5 cm are excluded from the study. There were a total of 32 patients, 20 males and 10 females, having a median age of 54.8 years. In the initial biopsy, only nine patients had malignancy results. The 23 cases having benign results had medical treatment with proton pump inhibitors for four weeks. At the end of this period, they had their second gastroscopic evaluation. The ulcers of 14 patients did not heal and second round biopsies were per formed. Additionally four cases had malignant results following the second round biopsy. After 4 weeks the remaining 10 cases had their third round of gastroscopy which revealed that two patients still had the ulcer. A third round biopsy was done and one case had a malignancy result. A total of 14 malignancy cases was encountered, and nine of them was adenocarcinoma, four were signet cell carcinoma and one case was MALT lymphoma. 78% of the malignant cases were encountered at the proximal site of the incisura angularis, and in 64% of these malignant cases nodular lesions around the ulcer were encountered. The four ulcers out of eight which were settled at the smaller curvature site were malignant, and only one ulcer at cardia was also malignant. The main method for the discrimination of malign-benign ulcer is still biopsy. The follow up of the patients with repeated multiple biopsies may increase the sensitivity for diagnosis of malignancies in the solitary gastric ulcer.