Risk of Bleeding After Percutaneous Endoscopic Gastrostomy in Patients Using Antithrombotic Drugs.

BACKGROUND: The rate of using antithrombotic (AT) drugs is frequently high in patients who require percutaneous endoscopic gastrostomy (PEG). The aim of this study was to determine whether the risk of bleeding after PEG increases in patients whose AT drugs were discontinued according to the European Society Gastrointestinal Endoscopy guidelines (warfarin for 5 d, low molecular weight heparin for 24 h, DOAC for 3 d, and clopidogrel for 7 d). PATIENTS AND METHODS: Data from 243 patients, who underwent PEG tube placement and received AT drugs and 206 patients who did not between 2018 and 2021 in our hospital, were evaluated retrospectively. Bleeding was defined as requiring blood transfusion, hematemesis and/or melena, decreased hemoglobin, or bleeding from PEG. RESULTS: A total of 243 (54.1%) patients (121 (49.7%), women, mean age (75.7 y) who underwent PEG and received AT drugs, and 206 (45.9%) patients who did not (92 (44.6%), women, mean age (63.15 y). The medications and bleeding rates of the patients are given in Table 1. The rate of bleeding in patients using AT medication was significantly higher than that in patients not using medication (Table 2) ( P = 0.007). When the AT drugs were compared among themselves, the bleeding risk did not differ. Bleeding was detected in 10 patients with bleeding from the PEG tube in 4 with melena. Bleeding detected in 14 patients was controlled with adrenaline injections. None of the patients required transfusion or repeat endoscopies. No bleeding-related deaths were reported. CONCLUSION: Even if patients receiving AT drugs are treated as recommended by international guidelines, it should be kept in mind that bleeding may occur after PEG, and the patients should be followed accordingly.

Clinical and Endoscopic Consequences of Delay in Stent Exchange Procedures With ERCP During the Covid-19 Pandemic.

INTRODUCTION: During the COVID-19 pandemic, elective endoscopic retrograde cholangiopancreatography (ERCP) procedures have been postponed as recommended by international guidelines. In this study, the results of biliary and pancreatic ERCP procedures that had to be postponed during the pandemic process were investigated. MATERIALS AND METHODS: Forty-seven patients whose stent exchange procedures with ERCP were postponed between March 2020 and June 2020 due to the COVID-19 pandemic were included in the study. Patients were evaluated in 2 groups as delayed biliary procedures (n: 32) and delayed pancreatic procedures (n: 15). Clinical problems (biliary or pancreatic pain, itching, cholangitis, etc.) and technical problems encountered during the procedure (stent migration, abundant stone sludge in the bile ducts, etc.) were compared with 46 patients who could be treated without delay (39 interventions for the biliary system and seven interventions for the pancreas). FINDINGS: Considering the procedures for the biliary system, there was no difference in age and sex between the groups. Although clinical problems in biliary procedures were more common in the group with delay than in those without delay, this difference was not significant (34% vs. 20%; P : 0.14). The technical problems encountered during the procedures in the group with delay were significantly higher than those without delay (21% vs. 2.5%; P : 0.019), with stent migration being the most common problem (n: 5). Age and sex did not differ in the patients who had pancreatic interventions with and without delay. The clinical problems that developed in the patients did not differ between the groups with and without delay (26% vs. 28%; P : 0.8). Although technical problems were encountered in 1 out of 15 patients in the group with delay, no technical problem was experienced in the group without delay ( P : 0.68). CONCLUSION: Postponing elective ERCP procedures for the biliary system not for the pancreatic system during the COVID-19 pandemic brings technical problems.

Human Leucocyte Antigen Genotyping in Celiac Disease: Reasons for Inappropriate Use.

BACKGROUND: Celiac disease (CD) is an autoimmune enteropathy, which may need further Human Leukocyte Antigen (HLA) testing beyond autoantibodies for diagnosis due to the necessity of lifetime gluten restriction. HLA genotyping test is useful in certain scenarios for CD diagnosis and screening. The aim of this study was to evaluate the reasons for inappropriate requesting of HLA testing. METHODS: One hundred and fifteen patients, who had been tested for CD-related HLAs, were included in this study. Final diagnosis, indication of HLA test, serological and histopathological findings were re-evaluated to determine the inappropriate usage of HLA testing. RESULTS: Among all patients, 44 (38.2%) were diagnosed with CD according to their genotyping results. The frequency of DQ 2.5, DQ8 and DQ2.2 haplotypes among these patients was 57.2%, 28.2%, and 14.3%, respectively. HLA test was performed inappropriately in 35 (30.4%) of patients. The most common reason was serology and pathological findings of patients were already conclusive as CD in 15 (42.9%) patients. Serology negative patients were tested without any supporting finding of CD in 11 (31.4%) patients. Last identified reason was that patients whose serology and intestinal biopsy were not conclusive as CD in 9 (25.7%) patients. CONCLUSIONS: Before requesting HLA typing test, patient's data should be thoroughly evaluated to confirm the need for test.

Retrospective Evaluation of Hepatitis C Awareness in Turkey Through Two Decades.

BACKGROUND/AIMS: Chronic hepatitis C (CHC) is the only viral infection that can be treated with oral antiviral agents. However, CHC awareness is a major barrier to the World Health Organization's target of eliminating hepatitis C virus (HCV) by 2030. Here, CHC awareness trends were analyzed in Hacettepe University Hospital, Turkey, between January 2000 and December 2017. MATERIALS AND METHODS: Central laboratory data were retrospectively analyzed for HCV test results (anti-HCV, HCV RNA, HCV genotype). After combining 548,141 anti-HCV test results, 395,103 cases were analyzed. The following two parameters were defined for CHC awareness: (1) the presence of HCV RNA results for anti-HCV positives and (2) the presence of a genotype result for HCV RNA positives. RESULTS: Anti-HCV positives were older than negatives (mean age-years ± SD, 59.4 ± 19.0 vs. 44.0 ± 18.9), and the positivity rate was higher in women than in men (1.4% vs. 1.0%). Anti-HCV positivity decreased from 3.1% to 0.6% from 2000 to 2015 and subsequently stabilized. The overall percentage of RNA testing among anti-HCV positives was 53.1% (range, 20%-70%), which stabilized at approximately 50% after 2010. The genotyping rate for RNA positives varied between 40% and 70%. The main genotype identified was genotype 1 (85.7%). CONCLUSION: In an ideal CHC awareness state, all anti-HCV positives should undergo RNA testing, and genotyping should be performed when RNA tests are positive. However, even in our referral center, the combined rate of RNA and genotype testing was only approximately 50% during the last 10 years.

Artificial intelligence to predict overall survivals of patients with cirrhosis and outcomes of variceal bleeding.

Background and Aim: The ability to predict survival in cirrhosis is essential to management. Artificial intelligence models are promising alternatives to current scores and staging systems. The objective of this study was to test the feasibility of such a model to predict the short- and long-term survival of patients with different stages of cirrhosis. Materials and Methods: Clinical, laboratory, and survival data of patients with cirrhosis were collected retrospectively. A machine learning model was designed using feature selection. The model's prediction performance was compared with the Model for End-stage Liver Disease-serum sodium (MELD-Na) and the Child-Turcotte-Pugh (CTP) scores using area under the curve (AUC) analysis. Results: The study population consisted of 124 cirrhotic patients. The AUC of the CTP score for 1-, 3-, and 12-month overall survival was 0.75 (CI:0.61-0.88), 0.77 (0.65-0.88), and 0.69 (CI:0.60-0.79), respectively. The AUC of the MELD-Na scores for the same time points was 0.7 (CI:0.62-0.86), 0.73 (CI:0.63-0.83), and 0.68 (CI:0.59-0.78). The machine learning model mean AUC for the entire study population was 0.87 (±0.082) for 1 month, 0.85 (±0.077) for 3 months, and 0.76 (±0.076) for 12 months. The model predicted 1-, 3-, and 12-month survival with an AUC of 0.91 (±0.03), 0.88 (±0.10), and 0.91 (±0.06), respectively, in patients with variceal bleeding. Conclusion: To the best of our knowledge, this is the first study to test a machine learning model in this context. The model outperformed the MELD-Na and CTP scores in the prediction of short- and long-term survival and also successfully predicted high risk variceal bleeding.

Evaluation of risk factors for the recurrence of colorectal polyps and colorectal cancer

Background/aim: Colorectal adenomatous polyps are precursors of colorectal cancer (CRC), which can be prevented with surveillance colonoscopy. This study aimed to assess risk factors for the recurrence of colorectal polyps and CRC following polypectomy. Materials and methods: In this single-center trial, a total of 510 patients who applied to the endoscopy unit of Hacettepe University Hospital for various reasons and who were diagnosed with at least one colorectal adenomatous polyp between 2000 and 2010 were retrospectively analyzed. Patients with colorectal adenomatous polyps or CRC recurrences were examined in terms of clinical and histological risk factors. Results: A total of 190 (37.1%) patients had surveillance colonoscopy. Among them, 127 (66.3%) were found to have polyp recurrence. Of the parameters defined for polyp recurrence, no association was found between the number of polyps (1-2, ≥3) (1-3, ≥4) in the first colonoscopy and diabetes mellitus, hypertension, hyperlipidemia, sex, family history of colon malignancy, smoking, alcohol usage, size of polyp (<10 mm, ≥10 mm), or advanced histologic type of polyp. The only significant difference was observed in patients who had left-sided colon polyps. In the basal colonoscopy, 130 patients had been diagnosed with CRC, and a significant correlation was found between the number of polyps (1, ≥2) and polyp size (≥10 mm), anemia, high sedimentation rate (>25), and CRC. In the first surveillance colonoscopy, CRC was detected in 12 patients. There was a significant correlation between the development of CRC and advanced histological type, anemia with high erythrocyte sedimentation rate, polyp size (<10 mm, ≥10 mm), and the number of polyps (<3, ≥3). Conclusion: Patients with left-sided colon polyps had a high risk of developing colorectal polyp recurrence. Moreover, the risk of developing CRC increased in patients who had advanced histology, a polyp larger than 10 mm, or more than three polyps.

Enteroscopic findings of Celiac Disease and their correlation with mucosal histopathologic changes.

BACKGROUND AND AIMS: Single Balloon Enteroscopy enables us to examine the small bowel for various diseases. It provides a view of the intestinal mucosa with biopsy capability, which may be helpful in search of a mucosal disease such as Celiac Disease. Celiac Disease is a proximal enteropathy developed in genetically susceptible individuals to wheat protein gluten. Examination of the duodenum and proximal jejunum are mostly diagnostic. We aimed to review enteroscopic findings of the patients with Celiac Disease. PATIENTS AND METHODS: Consecutive adult patients (>18y) who needed intestinal or duodenal biopsy for the diagnosis of the Celiac Disease were included. Single Balloon Enteroscopy system was used to enter the proximal jejunum. All of the patients had biopsies in order to diagnose Celiac Disease. RESULTS: Single Balloon Enteroscopy was performed in 33 patients. Twenty two (66.7%) subjects were diagnosed as Celiac Disease. The most common endoscopic abnormality in Celiac Disease was mucosal atrophy in 20 patients (90.9%), continuous involvement was the most common presentation (36.4%). All of the patients with Celiac Disease exhibited at least one endoscopic change. CONCLUSIONS: This study confirmed the patchy nature of the disease with mostly diffuse involvement of the small bowel. However, any endoscopic abnormality can be found in every patient with Celiac Disease. Analysis of images from either conventional upper endoscopy or capsule endoscopy may aid the diagnosis.

Gastroesophageal reflux disease prevalence in the city of Sivas.

BACKGROUND/AIMS: Epidemiological data of gastroesophageal reflux disease from Turkey is scarce. For this reason, we aimed to determine the gastroesophageal reflux disease prevalence in our region and to compare it with both the Western part of Turkey and with other countries in the world. MATERIAL AND METHODS: We used a previously validated reflux questionnaire and applied it to a random sample of 1345 subjects stratified by socio-economic status, who were older than 20 years and were living in the city center of Sivas. The questionnaire was conducted by medical students who were attending Public Health internship. RESULTS: We estimated a prevalence rate of 19.3% for gastroesophageal reflux disease, defined as heartburn and/or acid regurgitation at least once a week or more frequent. We found a significant association of gastroesophageal reflux disease with age, obesity, lying down within two hours after meals, and being under stress within the last one year, but not with smoking. Comorbid diseases associated with gastroesophageal reflux disease presence included recurrent pharyngitis, chronic cough, asthma, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease, but not coronary heart disease. 50.8% of our subjects had visited a physician for gastroesophageal reflux disease symptoms. The most common drug they used was proton pump inhibitors. CONCLUSION: The prevalence of gastroesophageal reflux disease in a city of the Middle Anatolian region of Turkey was similar to that in developed countries and also to the results of another study performed in the Western part of Turkey. Further studies are needed to elucidate the role of environmental factors in the development of gastroesophageal reflux disease.

Effects of L-thyroxine on gastric motility and ghrelin in subclinical hypothyroidism: a prospective study.

INTRODUCTION: Overt hypothyroidism affects the gastrointestinal system. Limited data are available regarding gastric motility in subclinical hypothyroidism (SCH). OBJECTIVE: The aim of this study was to assess gastric motility-related gastric symptoms and levels of ghrelin in patients with SCH compared with those in healthy control subjects and to evaluate the potential effects of l-thyroxine replacement therapy. METHODS: Twenty premenopausal women with SCH and 20 age- and body mass index-matched healthy control women were enrolled in the study. The gastroparesis cardinal severity index questionnaire was used to reveal gastrointestinal motility changes, and electrogastrographic activities were measured. Fasting and postprandial ghrelin levels at 30, 60, and 120 minutes were determined during a mixed meal test. All tests were repeated after 6 months when patients were in the euthyroid state. RESULTS: The gastroparesis cardinal severity index score, fasting tachygastria ratio, and postprandial/fasting bradygastria ratio in electrogastrography were higher in patients with SCH compared with control subjects (P = .03, P = .04, and P = .04, respectively). All 3 parameters significantly improved after l-thyroxine replacement therapy (P < .001, P = .005, and P =.02 respectively) reaching levels similar to those of control subjects. Baseline and area under the curve for ghrelin during mixed meal tests did not show a difference between patients with SCH and control subjects and before and after l-thyroxine replacement in SCH. CONCLUSION: Gastric dysmotility and the resultant upper gastrointestinal symptoms can be observed in SCH, and symptomatology related to dysmotility and parameters appear to be improved with thyroid hormone replacement. Our results also suggest that ghrelin levels in response to a meal are similar between women with SCH and healthy women and that normalization of thyroid function by l-thyroxine does not modulate these levels.

A model of complaint based for overcrowding emergency department: Five-Level Hacettepe Emergency Triage System.

BACKGROUND: To compare ESI Five-Level Triage System with 5-Level Hacettepe Emergency Triage System (HETS), which was developed for Overcrowded EDs in our country. METHODS: Over a period of six days, patients were assessed by a different ED staff everyday using HETS, then re-evaluated blindly by an emergency physician using HETS. Then patients were evaluated blindly for a third time by an independent, ESI-using emergency physician. RESULTS: Of the patients in the study, 133 were men, 175 were women and the average age was 44.41±18.033. Inter-rater agreement was 97.40% (Kappa=0.963) between HETS and HETS-Blind, 74.35% (Kappa=0.646) between HETS and ESI-Blind, 74.67% (Kappa=0.652) between HETS-Blind and ESI-Blind. Inter-observer agreement between the second emergency physician performing HETS-Blind and the first emergency physician, resident, or nurse was very good (Kappa=1.0). Intern doctor, non-medical secretary and paramedic were found to have almost very good agreement (Kappa=0.971; 0.935; 0.864, respectively). An overtriage of 7.25% and undertriage of 1.08% were found in HETS. CONCLUSION: Complaint-based HEST developed for overcrowded Eds is a triage system with a very good agreement between observations and observers. Low undertriage and overtriage ratios, and easy application by all staff from a non-medical secretary to the emergency physician.

Red cell distribution width can predict intestinal atrophy in selected patients with celiac disease.

BACKGROUND: Red cell distribution width (RDW) has been shown as a distinctive marker of mortality and morbidity in a wide spectrum of conditions related to systemic inflammation or deficiency of antioxidant nutrients. OBJECTIVE: We aimed to investigate the predictive value of RDW in detection of intestinal atrophy in celiac disease (CD). METHODS: Iron indices and RDW were studied in 49 patients with CD to evaluate the utilization of RDW as a predictive marker for presence of intestinal atrophy. RESULTS: Sixty-nine percent of patients had iron deficiency at initial presentation and 89% had abnormal RDW defined as >14. Receiver operating characteristics curves of RDW has been found to be a predictive of intestinal atrophy at levels higher than 17.25 (68% sensitivity and 85% specificity). In patients with transglutaminase antibody IgA titers >200 U/l, RDW level >17.75 showed 76% sensitivity and 100% specificity for intestinal atrophy. CONCLUSIONS: We suggest that RDW can be used as a surrogate marker of atrophy in patients with iron deficiency and suspected CD. In addition, the sensitivity, specificity, negative and positive predictive values of RDW increases when used in combination with high levels of transglutaminase IgA antibody.

Efficacy of a modified sequential therapy including bismuth subcitrate as first-line therapy to eradicate Helicobacter pylori in a Turkish population.

BACKGROUND: Eradication rates of Helicobacter pylori with standard triple therapy are not satisfactory. Sequential therapy is an alternative method to overcome this problem. OBJECTIVES: The aim of this study was to assess efficacy of a modified sequential therapy with the addition of a bismuth preparation, as first-line treatment in the eradication of H. pylori infection. MATERIALS AND METHODS: One hundred and forty-two H. pylori-positive patients were included in the study. Patients were given a 14-day sequential therapy program consisting of pantoprazole, 40 mg (b.i.d. for 14 days); colloidal bismuth subcitrate, 300 mg 4 (two tablets before breakfast and dinner, for 14 days); amoxicillin, 1 g (b.i.d.for the first 7 days); tetracycline, 500 mg (q.i.d. for the second 7 days); and metronidazole, 500 mg (t.i.d. for the second 7 days). Eradication was tested by urea breath test (UBT) 6 weeks after completion of treatment. RESULTS: Of the 142 patients included, 131 completed the study. "Per-protocol" and "intention-to-treat" analyses revealed high eradication rates in this group (92.0-95% CI, 87.2-96.8%, and 81.0-95% CI, 74.5-87.4%, respectively). There was no relation to sex and age with this modified sequential therapy. Compliance was satisfactory (11 patients - four women and seven men were unavailable for follow-up), and side effects were minimal (six patients had to stop treatment - metronidazole-related facial swelling and numbness on the face and hands in two patients; tetracycline-related fever and epigastric pain and nausea and vomiting in two patients; and amoxicillin-related diarrhea and vaginal discharge in two patients). These side effects were reversible and resolved after the cessation of the related medication. CONCLUSIONS: This 14-day modified sequential treatment, including bismuth, achieves a significantly high eradication rates in patients with H. pylori infection, with five satisfactory patient compliance and minor side effects.

Is enteroscopy necessary for diagnosis of celiac disease?

Celiac disease (CD) is an autoimmune inflammatory disease of the small intestine as a result of reaction to wheat protein, gluten. Exclusion of dietary gluten is the mainstay of the treatment that necessitates a precise diagnosis of the disease. Serological screening may aid in identifying patients with suspected CD, which should be confirmed by intestinal biopsy. It has been shown that duodenal biopsies are good for detection of the disease in most patients. However, there is a group of patients with positive serology and inconclusive pathology. As a result of the widespread use of serology, many patients with equivocal findings grow quickly. Unfortunately current endoscopic methods can only diagnose villous atrophy, which can be present in the later grades of disease (i.e., Marsh III). To diagnose CD correctly, going deeper in the intestine may be necessary. Enteroscopy can reveal changes in CD in the intestinal mucosa in 10%-17% of cases that have negative histology at initial workup. Invasiveness of the method limits its use. Capsule endoscopy may be a good substitute for enteroscopy. However, both techniques should be reserved for patients with suspected diagnosis of complications. This paper reviews the current literature in terms of the value of enteroscopy for diagnosis of CD.

A retrospective study demonstrating properties of nonvariceal upper gastrointestinal bleeding in Turkey.

BACKGROUND/AIMS: Helicobacter pylori infection, non-steroidal anti-inflammatory drugs and peptic ulcer are considered as the major factors for upper gastrointestinal system bleeding. The objective of the study was to determine the sociodemographic and etiologic factors, management and outcome of patients with non-variceal upper gastrointestinal system bleeding in Turkey. METHODS: Patients who admitted to hospitals with upper gastrointestinal system bleeding and in whom upper gastrointestinal endoscopy was performed were enrolled in this retrospective study. The detailed data of medical history, comorbid diseases, medications, admission to intensive care units, Helicobacter pylori infection, blood transfusion, upper gastrointestinal endoscopy, and treatment outcome were documented. RESULTS: The most frequent causes of bleeding (%) were duodenal ulcer (49.4), gastric ulcer (22.8), erosion (9.6), and cancer (2.2) among 1,711 lesions in endoscopic appearances of 1,339 patients from six centers. Seven hundred and four patients were evaluated for Helicobacter pylori infection and the test was positive in 45.6% of those patients. Comorbid diseases were present in 59.2% of the patients. The percentage of patients using acetylsalicylic acid and/or other non-steroidal anti-inflammatory drug was 54.3%. Bleeding was stopped with medical therapy in 66.9%. Only 3.7% of the patients underwent emergency surgery, and a 1.1% mortality rate was determined. CONCLUSIONS: Patients with upper gastrointestinal system bleeding were significantly older, more likely to be male, and more likely to use non-steroidal anti-inflammatory drugs. Though most of the patients were using gastro-protective agents, duodenal and gastric ulcers were the contributing factors in more than 70% of the upper gastrointestinal bleeding. The extensive use of non-steroidal anti-inflammatory drug is a hazardous health issue considering the use of these drugs in half of the patients.

Patient population and factors determining length of stay in adult ED of a Turkish University Medical Center.

This study is designed to analyze retrospectively patients who present to adult emergency department (ED) from January 1, 2002, to February 28, 2002. Age, sex, presentation time to ED, length of stay in emergency service, consultations, the number of patients who need to be hospitalized and also the number of hospitalized patients, diagnosis categories, and discharge instructions are analyzed. It is found that patients in most admissions are at 21 to 25 years of age. At night, the number of visits is decreased. Hospitalizations could be done to only about half of patients who in fact should be hospitalized. There is a correlation between the length of stay of patients in emergency service and the number of consultations per patient. There is also a correlation between patient complexity and length of stay in emergency service. The ED overcrowding rises with increased visits and patients staying in ED who should be hospitalized.

Capability of capsule endoscopy in detecting small bowel ulcers.

Capsule endoscopy (CE) has proved to be the preferred modality for mucosal pathologies of the small bowel. We evaluated the capability of CE for detecting small bowel ulcers and the contribution of CE in establishing the diagnosis. From a total of 66 patients who had undergone normal upper and lower endoscopy and small bowel follow-through, CE revealed previously undiagnosed ulcer(s) in the small intestines of 22 patients. Final diagnoses of the ulcers of these 22 patients were Crohn's disease (n = 9), Behçet's disease (n = 2), nonspecific jejunoileitis (n = 2), vasculitis (n = 1), gastrointestinal stromal tumor (n = 1), adenocarcinoma (n = 1), lymphoma (n = 1), multiple myeloma (n = 1), Meckel's diverticulum (n = 1) and unknown (n = 3). Capsule endoscopy was extremely useful in establishing the diagnosis. In this study, proximal, distal and diffuse small bowel ulcers were determined at rates of 27.3, 59.0 and 13.7%, respectively. Capsule endoscopy facilitated the detection and assessment of ulcerated mucosal lesions located in the small bowel.

How helpful is capsule endoscopy to surgeons?

Capsule endoscopy is a new technology that, for the first time, allows complete, non-invasive endoscopic imaging of the small bowel. The efficacy of capsule endoscopy in the diagnosis of suspected small bowel diseases has been established. Important applications for surgeons include observations of obscure gastrointestinal bleeding and small bowel neoplasms.