When abdominal pain knocks the door: an unusual presentation of chronic lymphocytic leukemia.

A 67-year-old man presented non-specific abdominal pain. Polypoid mass at appendiceal orifice in the cecum was found on endoscopic investigation without appendicitis sign. Histopathology elucidated underlying mucosal infiltration that was chronic lymphocytic leukemia. This is an isolated and unusual gastrointestinal involvement of hematologic disorder in an older patient.

Successful Treatment With Direct-Acting Antiviral Agents of Hepatitis C in Patients With End-Stage Renal Disease and Kidney Transplant Recipients.

OBJECTIVES: The introduction of direct-acting antiviral agents has allowed significant chances for treatment for difficult-to-treat populations. This study aimed to investigate the efficacy, tolerability, and safety of these therapies in both patients with end-stage renal disease and kidney transplant recipients with chronic hepatitis C virus infection. MATERIALS AND METHODS: This study was a retrospective analysis with prospective follow-up of patients. The antiviral combination of ombitasvir 25 mg, paritaprevir 75 mg, ritonavir 50 mg, and dasabuvir 50 mg was prescribed to patients with end-stage renal disease or kidney transplant recipients with noncirrhotic or compensated cirrhotic liver disease. The other antiviral combination consisted of sofosbuvir 400 mg and ledipasvir 90 mg, which was recommended to patients with decompensated cirrhosis or those who could not tolerate the first combination regimen. Ribavirin was given to all patients with genotype 1a hepatitis C virus infection. All clinical and laboratory data were recorded at week 4, at end of the treatment, and at 12 weeks after completion of treatment. RESULTS: In terms of efficacy, sustained virologic response at 12 weeks was achieved in 94% of patients in the end-stage renal disease group and 92% of patients in the kidney transplant group. In terms of tolerability, antiviral treatment was well tolerated in both groups. Cardiac arrest and cerebrovascular accident were seen in the end-stage renal disease group; severe mucositis and glossitis were seen in the kidney transplant group. Hospitalization was needed in 2 patients for treatment of drug interactions with tacrolimus and sirolimus. Renal allograft function worsened in 2 patients, with 1 patient having biopsyproven antibody-mediated rejection. CONCLUSIONS: We observed great efficacy and safety in both kidney transplant recipients and patients with end-stage renal disease with these agents in treatment of chronic hepatitis C. However, clinicians should remain aware of drug interactions and adverse events in this fragile patient population.

Liver Biopsy Results in Potential Donor Evaluation in Living Related Liver Transplant.

OBJECTIVES: The number of living-donor liver transplants has been increasing due to the growing discrepancy between the number of patients on wait lists for liver transplant and the availability of deceased donations. Evaluations of potential liver donors should ensure the safety of the surgical procedure for both the donor and recipient. Liver biopsy is the criterion standard for selecting optimal donors. In this study, we evaluated the importance of preoperative liver biopsy in selecting donor candidates. MATERIALS AND METHODS: We evaluated the data of 612 living-related liver donor candidates who received liver biopsies between January 2001 and June 2017 at our center. RESULTS: In the 612 liver donor candidates (328 male, 284 female; age range, 18-69 years), 416 liver biopsies (68%) were reported as normal and 196 liver biopsies (32%) had pathologic findings. Of 196 donors with pathologic findings, 86 (44%) had fatty changes and 24 (12%) had portal inflammation. CONCLUSIONS: The high rate of pathologic findings in liver biopsy of healthy-appearing donor candidates indicated the importance of liver biopsy in the preoperative evaluation of donors.

Endoscopic Retrograde Cholangiopancreatography in Kidney Transplant Patients: Results From a Single Center.

OBJECTIVES: We report the outcomes of endoscopic retrograde cholangiopancreatography procedures performed for diagnostic and therapeutic purposes in patients who had undergone kidney transplant. MATERIALS AND METHODS: We retrospectively evaluated the records of kidney transplant patients for January 1993 to December 2014. Endoscopic retrograde cholangiopancreatography was carried out using an Olympus JF240 duodenoscope (tip outer diameter 12.6 mm, working channel diameter 3.2 mm). The procedures were performed by Department of Anesthesiology staff while the patients were deeply sedated, given a combination of midazolam plus propofol. RESULTS: Data from 21 kidney transplant patients (16 men and 5 women; mean age at endoscopic retrograde cholangiopancreatography 42.6 ± 23.4 y) were evaluated. A total of 23 endoscopic retrograde cholangiopancreatography procedures were performed. The indications were choledocholithiasis in 6 patients (28.6%), common bile duct dilatation plus liver enzyme elevations in 4 patients (19%), liver enzyme elevation alone in 4 (19%), biliary necrotizing pancreatitis in 2 (9.6%), and cholangitis in 5 (23.8%). Hepatobiliary ultrasonography findings showed that 3 patients (14.3%) had absence of gallbladder owing to cholecystectomy, 14 (66.7%) had gallstones, 1 (4.7%) had gallstones with cholecystitis findings, and 3 (14.3%) were normal. Endoscopic retrograde cholangiopancreatography findings were normal in 4 patients (19%), showed cholangitis in 2 (9.6%), choledocholithiasis in 10 (47.6%), bile duct wall irregularities in 2 (9.6%), dilated common bile duct in 2 (9.6%), and cholangiocarcinoma in 1 (4.7%). Sphincterotomy was performed in 16 patients. None of the patients who underwent endoscopic retrograde cholangiopancreatography developed any complications, for example, acute pancreatitis, bleeding, duodenal, or bile duct perforation. CONCLUSIONS: In kidney transplant patients, endoscopic retrograde cholangiopancreatography is safe and able to provide substantial information for managing biliopancreatic diseases.

Hypovolemia-related gastric tissue damage in the setting of upper gastrointestinal bleeding.

BACKGROUND/AIMS: Much is known about the gastric tissue damage that is associated with hypovolemic stress, but gastrointestinal bleeding due to gastric injury and further gastric injury due to hypovolemia have not been evaluated in previous research. The aim of this study was to assess oxidative gastric tissue damage specifically linked to hypovolemia in patients with upper gastrointestinal bleeding. METHODS: The study included 30 patients who presented with acute upper gastrointestinal bleeding and 30 controls. Each patient's history and laboratory findings were recorded, and multiple biopsies of the gastric antrum were obtained at diagnostic endoscopy on admission (day 1) and five days later. A set of antral biopsies was also collected from each control subject. Each tissue specimen was analyzed for levels of glutathione peroxidase, superoxide dismutase and catalase activity, and level of malondialdehyde. RESULTS: First day glutathione peroxidase, superoxide dismutase and catalase levels were significantly lower and malondialdehyde levels were higher than on the 5th day, and 1st day and 5th day levels were significantly different from controls (p<0.05). A moderate level of correlation was detected between catalase and hemoglobin (r:-0.59) and hematocrit (r:-0.61) and between malondialdehyde and systolic blood pressure (p:0.58), hematocrit (r:0.45) and hemoglobin (r:0.49). CONCLUSIONS: In this study, gastric tissue oxidative markers showed antral oxidative changes to be significantly correlated with patients' hemodynamics. Oxidative stress may not be a clinical condition but it obviously shows gastric tissue damage and may explain many of the patients' additional diagnosis of gastric erosions. Interestingly, the oxidative change does not completely recover even on the 5th day.

Clinical characteristics of inflammatory bowel disease in Turkey: a multicenter epidemiologic survey.

AIM: To investigate the epidemiologic and clinical characteristics of inflammatory bowel disease (IBD) patients in a large multicenter, countrywide, hospital-based study in Turkey. MATERIALS AND METHODS: Twelve centers uniformly distributed throughout Turkey reported through a questionnaire the new IBD cases between 2001 and 2003. The incidence of ulcerative colitis (UC) and Crohn's disease (CD) has been reported per 100,000 people. Epidemiologic features and clinical characteristics of both diseases were analyzed. RESULTS: During the study period, 661 patients of UC and 216 patients of CD were identified. The incidence in the referral population was 4.4/100,000 and 2.2/100,000 for UC and CD, respectively. The age of the patients showed the characteristic biphasic distribution with 2 peaks between 20 and 30 and 50 and 70 years. A male predominance was observed in both diseases. A history of smoking was detected in 15.5% of UC patients and 49.3% of patients with CD. Family history was positive in 4.4% in UC and 8.3% in CD patients. Concomitant amebiasis was observed in 17.3% of patients with UC and 1.3% of patients with CD. A history of appendectomy was reported in 15% of patients with CD and only 3% of patients with UC. Both extraintestinal and local complications were more frequent in CD patients, whereas arthritis was most common in both diseases. CONCLUSIONS: IBDs are frequently encountered in Turkey. IBD incidence is lower than North and West Europe but close to Middle East in our country. The majority of IBD cases are diagnosed in young people (20 to 40 y) with predominance in males. The rate of both intestinal and extraintestinal complications in our population was low when compared with the data reported in the literature. IBD and especially UC, can coexist with amebiasis or become manifest with amebic infestation. The presence of concomitant ameba may create confusion and cause dilemmas in the diagnosis and treatment of UC.

Pancreatic pseudocyst development due to organophosphate poisoning.

BACKGROUND/AIMS: Acute pancreatitis is a serious complication of organophosphate poisoning. There is no report in the literature dealing with the development of a pancreatic pseudocyst after complication of organophosphate-induced acute pancreatitis. Therefore, we present a case who developed pancreatic pseudocyst after complication of organophosphate-induced acute pancreatitis. METHODS: A 17-year-old female patient with a history of ingestion of complication of organophosphate insecticide (DDVP EC 550, dichlorvos) was admitted with cholinergic symptoms. On admission, serum amylase and lipase levels were high and abdominal ultrasonography showed an edematous pancreas. No etiological factor for acute pancreatitis was evident. RESULTS: We diagnosed complication of organophosphate-induced acute pancreatitis. After four weeks, abdominal abdominal ultrasonography and computerized tomography revealed a pancreatic pseudocyst of 6 cm diameter. During follow-up, the pancreatic pseudocyst size regressed to 4 cm. CONCLUSION: Complication of organophosphate poisoning can cause acute pancreatitis and its complications. Early diagnosis and appropriate treatment may reduce morbidity and mortality.

Gastric tissue oxidative changes in portal hypertension and cirrhosis.

Gastric mucosal lesions are very common in portal hypertension and cirrhosis. The aim of this study was to assess for oxidative gastric tissue damage in cirrhosis and evaluate relations with portal hypertension and cirrhosis parameters. The study included 30 patients with cirrhosis and 30 controls. Each patient's history, physical examination, and laboratory findings were recorded, and multiple biopsies of the gastric antrum were obtained at endoscopy. A set of antral biopsies was also collected from each control subject. Each tissue specimen was analyzed for levels of glutathione peroxidase (GPX), superoxide dismutase (SOD), and catalase (CAT) activity and level of malondialdehyde (MDA). Patients' gastric GPX, SOD, and CAT levels were significantly lower, and MDA levels were higher, than in the control group. The GPX activity level in the specimens was moderately negatively correlated with portal vein diameter (P<0.05, r=-0.45) and spleen length (P<0.05, r=-0.45). In this study gastric tissue oxidative markers showed that antral oxidative factors worsen in cirrhosis. Oxidative stress may not be a clinical condition but it obviously shows gastric tissue damage and may explain many patients' gastric lesions and hemorrhage.

Role of matrix metalloproteinase-7 in colorectal adenomas.

Matrix metalloproteinases (MMPs) degregade and remodel the extracellular matrix. They are known to be overexpressed as normal mucosa progresses to adenomas and carcinomas. In our prospective study we measured the overexpression of MMP-7 immunohistochemically in various types of colonic adenomas. Although MMP-7 has already been shown to be overexpressed in various types of colonic adenomas, tubular versus villous adenomas had not been further seperated to date. Seventy-six patients had either normal mucosa (n=15) or tubular (n=32), tubulovillous (n=16), or villous (n=13) colonic adenoma. MMP-7 expression was classified into three categories, as negative, weakly stained, or strongly stained, depending on the percentage of cells stained. Each adenoma was graded according to the percentage of strongly stained areas in the adenoma as G0, G1, G2, or G3. Sixty-nine percent of villous adenomas showed grade 3 staining of MMP-7, versus none of the tubular adenomas. G0 and G1 staining was not detected in the villous adenomas. The results of the study show that the degrees of overexpression of the three subtypes of colonic adenomas were statistically significantly different. In conclusion, MMP-7 overexpression is thought to be an early event in the adenoma-carcinoma pathway.

The relationship of heart rate variability with severity and prognosis of cirrhosis.

Many studies have demonstrated that cirrhosis is frequently associated with autonomic dysfunction. The aim of this study was to test autonomic dysfunction in cirrhotic patients by analyzing heart rate variability (HRV), to determine whether or not the degree of autonomic dysfunction is correlated with the severity of disease, and, also, to compare the changes of HRV between survivor and nonsurvivor groups after 2-year follow-up periods. HRV was analyzed using 24-hr ECG recording in 30 cirrhotic patients and 28 normal controls. The changes in HRV parameters including mean normal-to-normal (N-N) interbeat intervals (mean NN), standard deviation of all N-N intervals (SDNN), standard deviation of the average of N-N intervals for each 5-min period over 24 hr (SDANN), root mean square succesive differences (r-MSSD; msec), and percentage of adjacent N-N intervals that are >50 msec apart (pNN50), all as time domain parameters, were evaluated. The cirrhotic patients were also evaluated according to Child-Pugh classification scores as markers of the disease severity. The time-domain measures of HRV in cirrhotic patients were significantly reduced compared with those in the control group (for all parameters; P < 0.001). The severity of disease was associated with reduced HRV measures (for all parameters; P < 0.001). After the 2-year follow-up periods, HRV measurements in cirrhotic patients were significantly much lower in nonsurvivors than in survivors (P < 0.001 for all). We conclude that increasing severity of cirrhosis is associated with a reduction in HRV. This finding may be an indicator of poor prognosis and mortality for cirrhosis.

The effects of Gingko biloba extract on acetic acid-induced colitis in rats.

BACKGROUND/AIMS: Gingko biloba is an antioxidant substance which has antagonistic activity on platelet-activating factor. We aimed to investigate the antioxidant effect and the histopathologic changes caused by Gingko biloba on acetic acid-induced colitis. METHODS: Totally 22 rats were divided into three groups. Group 1 (n=7) served as the control group. Group 2 (n=7) and Group 3 (n=8) were given 2 ml/day of 4% acetic acid by intracolonic instillation for three days. Gingko biloba (100 mg/kg) was then given only to Group 3 intraperitoneally for three days. Oxidative stress was assessed by determinate tissue and serum malondialdehyde (MDA) levels, and colonic damage was assessed by histologic examination. RESULTS: Depth of necrosis, extent of necrosis, degree of inflammation, extent of inflammation, fibrosis and total histologic scores in Group 2 were significantly higher than in the control group (p<0.05). The same parameters were lower in Group 3 versus Group 2, but the difference was not significant. Tissue and serum MDA levels in Group 2 were significantly higher than Group 1 (p<0.01 and 0.05, respectively). Again, the same parameters in Group 3 were lower than in Group 2, but the difference was not significant statistically. CONCLUSIONS: Gingko biloba did not significantly affect histopathological and oxidative stress parameters in experimental colitis.

Spontaneous bacterial peritonitis due to Brucella Melitensis in a cirrhotic patient.

Spontaneous bacterial peritonitis is a well-known entity, with a reported incidence of 15-20% in advanced cirrhotic patients. Escherichia coli and Klebsiella pneumoniae are the most common causes of spontaneous bacterial peritonitis; Brucella is extremely rare. We aimed to present one case of such a rare condition in a cirrhotic patient who also had hepatocellular carcinoma. Routine laboratory tests, abdominal ultrasonography and peritoneal fluid examinations were studied in a cirrhotic patient with ascites. Peritoneal fluid white blood cell count was 1300/mm3, with lymphocyte predominance (80%). Peritoneal fluid and blood culture both yielded Brucella melitensis. The patient also had a mass in the right lobe of the liver confirmed as hepatocellular carcinoma by biopsy. Brucella should be suspected as a cause of spontaneous bacterial peritonitis in cirrhotic patients with no response to standard spontaneous bacterial peritonitis treatments and with immunodeficiency such as hepatocellular carcinoma.

QT interval analysis in patients with acute biliary pancreatitis.

BACKGROUND: It has been previously proposed that electrocardiographic abnormalities may be associated with acute pancreatitis. However, there is a lack of data on the QT interval and dispersion value in patients with acute pancreatitis, and no data are also available concerning QT interval and QT dispersion in acute biliary pancreatitis (ABP). AIMS: : We aimed to investigate the QT parameters in patients with ABP, to compare them with those of healthy controls, and to analyze the relationship between QT parameters and Ranson score. METHODS: The present study included 32 patients with acute biliary pancreatitis and 35 healthy controls. The severity of the pancreatitis was determined by Atlanta criteria: fewer than 3 Ranson criteria or fewer than 8 APACHE II (the Acute Physiology and Chronic Health Evaluation) points indicated the mild disease (group 1); 3 or more Ranson criteria or 8 or more APACHE II points or organ failure or systemic complications or local complications indicated the severe disease (group 2). On admission, all patients underwent a standard 12-lead electrocardiogram, and corrected maximum QTc interval (QTcmax), corrected minimum QT interval (QTcmin), and corrected QTc dispersion (QTcd) values of the subjects were measured according to the Bazett formula in this study. RESULTS: QTcmax and QTcd were significantly longer in patients with ABP than in healthy controls (442 +/- 38 milliseconds versus 413 +/- 34 milliseconds, P < 0.05; and 67 +/- 21 milliseconds versus 42 +/- 18 milliseconds, P < 0.001, respectively). Similarly, QTcmax and QTcd were significantly longer in group 2 than in group 1 (440 +/- 38 milliseconds versus 450 +/- 34 milliseconds, P < 0.01; and 66 +/- 9 milliseconds versus 71 +/- 11 milliseconds, P < 0.01, respectively). Correlation analysis showed that there is a significant positive relationship between Ranson scores of patients and QTcmax and QTcd (P < 0.01 and P < 0.001, respectively). CONCLUSION: The effect of acute biliary pancreatitis on QT intervals and dispersion appears to be dependent not only on the disease but also on its severity, and these parameters may give additional prognostic information in ABP patients, even in the initial evaluation.

Brain natriuretic peptide and severity of disease in non-alcoholic cirrhotic patients.

BACKGROUND: Cirrhotic patients have a hyperdynamic systemic circulation. They have insidious cardiac problems besides well-known complications. Brain natriuretic peptide (BNP) relaxes vascular smooth muscle and has a portal hypotensive action. The relations between BNP levels and severity of disease, cardiac dysfunction and esophageal varices were studied in non-alcoholic cirrhotic patients. METHODS: Fifty-two non-alcoholic cirrhotic patients were evaluated for decompensation component of cirrhosis. The BNP concentration of echocardiographically examined patients was determined. RESULTS: The BNP levels were significantly higher in ascites, spontaneous bacterial peritonitis and hepatic encephalopathy history group (P = 0.033, P < 0.001, P = 0.014, respectively), but no significant difference were observed for presence of esophageal varices and bleeding history (P = 0.267, P = 0.429). A significant correlation was observed between BNP concentration and Child score (r = 0.427, P = 0.012), interventricular septal thickness (r = 0.497, P < 0.001) and left ventricular posterior wall thickness (r = 0.526, P < 0.001). According to Child-Pugh classification there were no significant difference between groups for echocardiographic measurements and blood pressure (P > 0.05), but plasma BNP levels were significantly higher in Child class B and C patients compared with class A patients (P < 0.05). CONCLUSION: Increased levels of BNP are more likely related to the severity of disease in non-alcoholic cirrhotic patients. The advanced cirrhosis is associated with more advanced cardiac dysfunction and BNP has prognostic value in progression of cirrhosis.

The significance of corpus anterior wall ulcers on morbidity and mortality of patients with upper gastrointestinal bleeding.

BACKGROUND/AIMS: Acute upper gastrointestinal bleeding is a common and potentially life-threatening medical emergency. Various factors modulating morbidity and mortality on upper gastrointestinal bleeding have been reported. However, there are no reports on the prognosis of bleeding ulcers on the anterior wall of corpus (on fundus-corpus junction, 10-15 mm from the lesser curvature) bleeding ulcers on the anterior wall of the corpus. Thus, in this trial we tried to investigate the role of bleeding ulcers on the anterior wall of the corpus on acute upper gastrointestinal bleeding mortality and morbidity. METHODS: One hundred seventy-seven (63 women and 114 men, mean age 52 years) patients with a clinical diagnosis of upper gastrointestinal bleeding were endoscoped between August 1999 and December 2002. All patients were treated endoscopically, medically or with surgery. The site of the bleeding was noted and compared regarding rebleeding and mortality rates. RESULTS: 50% (3/6) of the patients with bleeding ulcers on the anterior wall of the corpus required further surgical procedure or were associated with mortality, but only 7% (12/171) of the patients with bleeding sites other than bleeding ulcers on the anterior wall of the corpus had mortality or required further surgical intervention (p<0.05). Recurrent bleeding occurred in 50% (3/6) of our patients with bleeding ulcers on the anterior wall of the corpus during their hospitalization compared to 7.60% (13/171) (p<0.05) of patients with bleeding sites other than bleeding ulcers on the anterior wall of the corpus. CONCLUSIONS: Bleeding ulcers on the anterior wall of the corpus is indicative of recurrence or persistence of the hemorrhage and of greater mortality. Bleeding from this site needs more aggressive and diligent care.

Association of peripapillary fistula with common bile duct stones and cholangitis.

BACKGROUND: Peripapillary choledochoduodenal fistula (PCDF) is occasionally detected during endoscopic retrograde cholangiopancreatography. Cholelithiasis and biliary bougienage are two suspected causes of PCDF. METHODS: The medical records for 841 patients who underwent endoscopic retrograde cholangiopancreatography between 1993 and 2002 were reviewed for evaluation of PCDF. RESULTS: A total of 327 patients had common bile duct stones, and 16 of these had a PCDF at the papilla of Vater. None of the 16 patients had a history of pancreatitis, duodenal ulcer, or had undergone endoscopic retrograde cholangiopancreatography previously. Seven of the 16 had not undergone biliary surgery. CONCLUSIONS: This study indicates that PCDF is a relatively common complication of common bile duct stones and cholangitis. According to the present results, PCDF is more frequently associated with common bile duct stones than with biliary surgery and bougienage.