Immunoglobulin G4-related diseases: Autoimmune pancreatitis and cholangitis.

OBJECTIVE: Autoimmune pancreatitis (AIP) and cholangitis are chronic inflammatory diseases characterized by the infiltration of lymphoplasmocytic cells into the pancreas and biliary tract and fibrosis. This is often accompanied by increased serum immunoglobulin G4 (IgG4) levels. An early and accurate diagnosis is extremely important because they display similar features to other malignant diseases of the pancreas and biliary tract and primary sclerosing cholangitis. In this study, we aimed to convey our clinic's experiences on this topic. METHODS: The patients who were diagnosed with IgG4 (+)/(-) AIP and IgG4 (+) sclerosing cholangitis by excluding other causes with clinical, radiological, serological, and pathological examinations and treatment response between July 2014 and June 2020 were included in the study. The data of the patients were analyzed retrospectively. RESULTS: A total of 12 patients, 8 men and 4 women, were included in the study. The mean age of the patients was 39.4 (13-66) years. Abdominal pain of varying degrees was the main reason for admission in all patients. The time of diagnosis and follow-up was 19.2 (2-66) months on average. The average number of attacks during the follow-up was 2.9 (2-8) times. The average IgG4 level of the patients was calculated as 250.1 (133-409) mg/dL. All the patients were given 24-48 mg methylprednisolone at reduced doses for 6-8 weeks. CONCLUSION: High serum IgG4 levels are the key indicators for diagnosis, and an early and accurate differential diagnosis is extremely important for malignant diseases of the pancreas and biliary tract. A good response to steroids is an important criterion for diagnosis as well as treatment.

Rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibodies with hepatitis B and hepatitis C infection: Review.

BACKGROUND: Viruses are common and are involved in the etiology of idiopathic rheumatological diseases. Hepatitis B virus (HBV), a member of the family Hepadnaviridae and hepatitis C virus (HCV), play an important role in the undetermined etiology of arthritis. The clinical manifestations of hepatitis B and C show similarities with various diseases, such as rheumatic diseases. Anti-cyclic citrullinated peptide (anti-CCP) is a specific serological marker for rheumatoid arthritis. OBJECTIVES: The aim of this study was to analyze anti-CCP and rheumatoid factor (RF) levels in patients with a hepatitis B and C infection. MATERIAL AND METHODS: Forty-four patients with hepatitis B, 43 patients with hepatitis C, 25 patients with rheumatoid arthritis, and 46 healthy control serums and their RF and anti-CCP levels were compared. RF was measured by the nephelometer, which detects IgM-RF. Anti-CCP was measured using enzymelinked immunosorbent assay (ELISA) that is included in the second-generation anti-CCP antibody assays (anti-CCP2). RESULTS: The anti-CCP positivity levels were 20.5%, 32.5%, 72.4% and 10.9% for HBV, HCV and RA groups and healthy control group, respectively. When the groups were compared based on their RF positivity and anti-CCP positivity while the values for HBV and HCV group and healthy control group were the same, in RA group there is a significant difference to the rest of the groups (p < 0.01). CONCLUSIONS: Anti-CCP may be positive for HBV and HCV as well, but it is a sensitive and specific immunological marker for RA diagnosis, especially in high-titres.

Study of ideal topical pharyngeal anesthesia in upper gastrointestinal system endoscopy: A double-blind, randomized, controlled trial.

BACKGROUND/AIMS: This study is designed to determine which drug forms provide ideal pharyngeal anesthesia when used during upper gastrointestinal system endoscopy. MATERIALS AND METHODS: A total of 180 patients were included in the study. Using the random number table, these patients were divided into three groups. Group 1, lidocaine gel+isotonic spray; Group 2, base lubricant gel+lidocaine spray; and Group 3: lidocaine gel+lidocaine spray. Data were collected from the patient identification form, compliance to operation form, and State Anxiety Inventory. RESULTS: Anesthetization and compliance to procedure scores were higher and anxiety scores were lower in Group 3 than in other groups (p<0.05). It was observed that as the compliance score increased, the anesthetization and satisfaction scores also increased; however, coughing during the procedure, duration of the procedure, and anxiety scores decreased (p<0.05). It was determined that as anesthetization scores increased, discomfort in the throat caused by the device, coughing during the procedure, and anxiety scores decreased (p<0.05). CONCLUSION: Lidocaine gel and spray combination is the most ideal pharyngeal anesthesia to ensure the adaptation of the patient to the procedure and to decrease anxiety and discomfort during the procedure.

Drug-induced esophageal ulcers: case series and the review of the literature.

BACKGROUNDS/AIMS: Drugs can cause several complications in the esophagus and lead to pill esophagitis. In this paper, our purpose is to share our clinical experience in light of the literature and put forward the general characteristics of pill esophagitis. MATERIALS AND METHODS: In our clinic, between January 2008 and June 2012, by excluding other factors, 48 patients were included in the study, diagnosed as drug-induced esophagitis with their history, endoscopic view, and histopathologic evaluation. RESULTS: There were 34 (70.9%) female and 14 (29.1%) male patients in the study, and their average ages were 35.1 and 32.4, respectively. Clinical symptoms were odynophagia (79.1%), retrosternal pain (62.5%), and dysphagia (47.9%). The reason for these symptoms for 85.5% of the patients was related to insufficient water consumption while taking the pill, taking the pill in recumbent position, or both. Tetracycline and its variant, doxycycline, were responsible for 52% of the patients, and 62.5% of the drugs were in capsule form. Ulcers were at the proximal and middle third of the esophagus in 79.2% of the patients. In the histopathologic evaluation, nonspecific acute inflammatory changes were found in 29.1% of the cases. Various proton pump inhibitors and sucralfate were used in the treatment. While no perforation and structure were detected, 1 patient died because of repetitive arterial bleeding. CONCLUSION: Almost every kind of drug, particularly doxycycline, can cause ulcer in the esophagus. Pill esophagitis can be prevented by warning patients about drinking water sufficiently and sitting up while taking the pill.

Drug- and herb-induced liver injury: a case series from a single center.

BACKGROUND/AIMS: Drug-induced liver injury (DILI) is common worldwide and has a potentially fatal outcome. It accounts for more than half of the cases of acute liver failure in the United States. Herb-induced liver injury (HILI) is a less documented condition but a growing problem. We present here the clinical characteristics and outcome of patients with drug- and herb-induced liver injury from our center. MATERIALS AND METHODS: In this 4-year retrospective study, 82 patients in whom there was a causal or highly probable relationship between herbal medicine or drug use and liver disease are presented. RESULTS: The mean age of patients was 43.1±14.8 years; sexual distribution was 53 females and 29 males. The major cause of hepatotoxicity was drugs (87.8%), with herbal medicine accounting for 12.2%. The leading causative agents were nonsteroidal anti-inflammatory drugs (NSAIDs) (23.1%), followed by antibiotics (19.5%). The pattern of hepatotoxicity was hepatocellular in 35 patients (42.6%), mixed in 28 (34.1%), and cholestatic in 19 patients (23.1%). Teucrium polium (known popularly as felty germander), which is a traditionally used herbal medicine of the Labiatae family in our region, was the most common cause of herb-induced liver injury and responsible in 7 of 10 herbal hepatotoxic cases. Acute liver failure developed in 3 patients (two patients related with flurbiprofen and diclofenac and one patient due to an isoniazid-rifampicin combination). CONCLUSION: Antibiotics and NSAIDs were the most common etiologic agents for drug-induced liver injury. Surprisingly, herbs follow these groups of drugs and must be questioned more carefully.

Postpartum hepatotoxicity due to herbal medicine Teucrium polium.

The hepatotoxicity cases due to herbal medical products have been increased in recent years. Teucrium polium (TP) (mountain germander) is one of the most popular species of the Lamiaceae family and is commonly used for increasing breast milk formation and for relieving gastrointestinal complaints in the last months of pregnancy and postpartum periods. Here are presented 3 cases of serious hepatotoxicity due to TP. Three female patients aged 33, 31, and 37 years were admitted to clinic with jaundice and serious elevated liver enzymes for a period of 2 years. The patients were using TP for approximately 40 days to 3 months. Two of the 3 used TP during their previous pregnancies and were monitored for similar complaints by another center. After discontinuation of TP and supportive care, the liver function tests were decreased to normal limits within 3 months in all 3 patients. In addition to the potential hepatotoxic effect of TP, physiological changes in the postpartum period may increase the severity of hepatotoxicity. TP should be considered in differential diagnosis in patients presenting similar history and complaints, where it is used commonly.

Peginterferon alfa related psoriasis in a patient with acute hepatitis C and review of the literature.

The Interferon (IFN) which is the standard treatment for Hepatitis C, may cause a lot of side effects including dermatological anomalies. This paper presents a psoriasis case which occurred in relation with the treatment of acute hepatitis C (AHC) with peginterferon alfa (peg-IFN-α). A 60-year-old male patient came to the hospital with symptoms of high liver enzymes. The patient with history of a recent operation showed anti-HCV(+), HCVRNA 3.5 million IU/mL and HCV genotype 1b in the tests. Without any other etiological factors found in the patient, we started a treatment of peg-IFNα-2b with the diagnosis of AHC. After 3 weeks, psoriatic plaques were observed in various parts of the body. Antiviral treatment of the patient was concluded within 6 months. His psoriasis treatment initially commenced with local agents followed by phototherapy. Permanent viral response was seen in the patient and his lesions recovered rapidly after the antipsoriatic and antiviral treatment. Psoriasis and other autoimmune diseases should be considered even though they are encountered rarely,and the patients should be informed of the possible risks before planning treatment with peg-IFN-α.