TASL Practice Guidance on the Clinical Assessment and Management of Patients with Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is a multisystem disease and is significantly associated with obesity, insulin resistance, type 2 diabetes mellitus, metabolic syndrome, and cardiovascular disease. NAFLD has become the most prevalent chronic liver disease in Western countries, and the proportion of NAFLD-related cirrhosis among patients on liver transplantation waiting lists has increased. In light of the accumulated data about NAFLD, and to provide a common approach with multi-disciplines dealing with the subject, it has become necessary to create new guidance for diagnosing and treating NAFLD. This guidance was prepared following an interdisciplinary study under the leadership of the Turkish Association for the Study of the Liver (TASL), Fatty Liver Special Interest Group. This new TASL Guidance is a practical application guide on NAFLD and was prepared to standardize the clinical approach to diagnosing and treating NAFLD patients. This guidance reflects many advances in the field of NAFLD. The proposals in this guidance are meant to aid decision-making in clinical practice. The guidance is primarily intended for gastroenterology, endocrinology, metabolism diseases, cardiology, internal medicine, pediatric specialists, and family medicine specialists.

Preventative Effect of Vitamin E on Mast Cells in Carbon Tetrachlorideinduced Acute Liver Damage

BACKGROUND

Preventing liver damage that might lead to cirrhosis is very important in the early stages of injury to that organ. The role of mast cells (MCs) in liver injuries has been long debated, and vitamin E is a well-known antioxidant used to treat those injuries. This study aimed to determine the protective role of vitamin E on MCs in injury to the liver that is triggered by carbon tetrachloride (CCl4). There is a correlation between MC deposits and improvement in fibrosis tissues.

METHODS

To further examine this, 68 male Albino Wistar rats were divided randomly into five groups: the control group, the vitamin E group, the CCl4 group, the CCl4 + vitamin E group, and the vitamin E + CCl4 group. Malondialdehyde (MDA) analysis, MC counts, histopathological investigation, and statistical analyses were used to evaluate the findings.

RESULTS

The administration of CCl4 resulted in an increase in the accumulation of MCs, degenerative parenchyma cells, MDA level, steatosis and inflammation. Additionally, proliferation of the bile ducts in the portal area and porto-portal and porto-central fibrosis were observed in the CCl4 group. In contrast, in the vitamin E group and in the groups administered a combination of vitamin E and CCl4, vitamin E prevented these increases.

CONCLUSION

It was concluded that the significant decrease in the MC counts, in the level of MDA and the number of degenerative cells, as well as a decrease in the steatosis and inflammation scores showed that vitamin E could prevent liver injuries by protecting the organ's histological architecture. Finally, the results indicate that vitamin E has positive effects on liver injuries.

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.

Long-term entecavir or tenofovir disoproxil fumarate therapy in treatment-naïve chronic hepatitis B patients in the real-world setting

The aim of this study was to determine the long-term efficacy of entecavir (ETV) and tenofovir disoproxil fumarate (TDF) on the natural course of disease in chronic hepatitis B patients (CHB) with/without cirrhosis in clinical practice. A total of 355 treatment-naïve CHB patients were enrolled into the study. The primary outcome measure was viral suppression as defined by serum HBV DNA level <20 IU/mL. A secondary outcome measure was to determine the development of Hepatocellular carcinoma (HCC). Virological and biochemical responses were similar between the two treatment groups over time. The presence of cirrhosis and hepatitis B e antigen (HBeAg) positivity did not appear to impact viral suppression. The cumulative probability of HBeAg loss was 41% at 4 years of therapy. Hepatitis B surface antigen (HBsAg) loss occurred in four patients. Model for End-Stage Liver Disease score was significantly improved from baseline to week 48 and 96 under antiviral therapy (P = 0.013, P = 0.01). HCC was diagnosed in 17 patients (4.8%). The cumulative probability of the development of HCC was 3.3% at 1 year and 7.3% at 4 years of therapy. The development of HCC was independently associated with older age (P = 0.031) and the presence of cirrhosis (P = 0.004). Serum creatinine levels and creatinine clearance remained stable over time. ETV and TDF effectively maintained virological and biochemical responses in long-term follow-up of CHB patients with/without cirrhosis. HCC may still develop, although at a lower rate, and is more likely to develop in patients with cirrhosis, especially in older patients.

Transnasal Endoscopy is Preferred by Transoral Endoscopy Experienced Patients

Background & Aims: Both unsedated transoral endoscopy (TOE) and sedated TOE have some drawbacks in clinical practice. Unsedated transnasal endoscopy (TNE) has been suggested as an alternative to both methods. This study aimed to determine the advantages of TNE in patients who have previously undergone unsedated conventional TOE.Methods: Patients who had received an unsedated TOE in the last 12 months and were scheduled for a second upper endoscopy were included. They were randomized to undergo either unsedated TOE, using a standard endoscope, or unsedated TNE, using an ultrathin endoscope. Post-procedure, patients were asked to complete a questionnaire to assess pain, discomfort and acceptability of the procedure, and to compare the current procedure with their previous unsedated TOE. Endoscope insertion rate, procedure duration, and side-effects were recorded.Results: Each group included 50 patients. With the exception of nasal pain, the tolerability and acceptance were significantly greater in the unsedated TNE group. Significantly more TNE patients (82%) found the current endoscopic procedure to be better than their previous TOE when compared with patients who had received a second TOE (12%). A repeat procedure was significantly more acceptable for TNE patients when compared to the TOE group (68% vs.16%). The duration of endoscopy was significantly shorter in TOE than in TNE (p<0.05). Endoscope insertion failed in 4% and mild epistaxis was observed in 4% of TNE patients.Conclusion: Unsedated TNE was better tolerated in endoscopy experienced patients when compared with unsedated TOE. The majority of patients found TNE more acceptable and preferable to TOE, suggesting that TNE should become a more common practice in clinics when applicable.

Transnasal endoscopy is preferred by transoral endoscopy experienced patients

BACKGROUND & AIMS

Both unsedated transoral endoscopy (TOE) and sedated TOE have some drawbacks in clinical practice. Unsedated transnasal endoscopy (TNE) has been suggested as an alternative to both methods. This study aimed to determine the advantages of TNE in patients who have previously undergone unsedated conventional TOE.

METHODS

Patients who had received an unsedated TOE in the last 12 months and were scheduled for a second upper endoscopy were included. They were randomized to undergo either unsedated TOE, using a standard endoscope, or unsedated TNE, using an ultrathin endoscope. Post-procedure, patients were asked to complete a questionnaire to assess pain, discomfort and acceptability of the procedure, and to compare the current procedure with their previous unsedated TOE. Endoscope insertion rate, procedure duration, and side-effects were recorded.

RESULTS

Each group included 50 patients. With the exception of nasal pain, the tolerability and acceptance were significantly greater in the unsedated TNE group. Significantly more TNE patients (82%) found the current endoscopic procedure to be better than their previous TOE when compared with patients who had received a second TOE (12%). A repeat procedure was significantly more acceptable for TNE patients when compared to the TOE group (68% vs.16%). The duration of endoscopy was significantly shorter in TOE than in TNE (p<0.05). Endoscope insertion failed in 4% and mild epistaxis was observed in 4% of TNE patients.

CONCLUSION

Unsedated TNE was better tolerated in endoscopy experienced patients when compared with unsedated TOE. The majority of patients found TNE more acceptable and preferable to TOE, suggesting that TNE should become a more common practice in clinics when applicable.

The relation between serum cytokeratin 18 and acute pancreatitis: can it be a serological predictive marker?

BACKGROUND/AIMS

Acute pancreatitis is well defined as pancreatic inflammation due to the activation of pancreatic enzymes secondary to several etiological factors. In the majority of patients, the clinical symptoms are self-limited, but it can also cause tissue necrosis and severe organ failures. In experimental animal models, it has been shown that wide apoptotic cell death is related to a clinically mild presentation of acute pancreatitis. Cytokeratin 18, a cytoskeletal protein, is shown to be related with apoptosis. In this study, we aimed to show the relation between serum cytokeratin 18 and the clinical presentation of acute pancreatitis in humans.

MATERIALS AND METHODS

A total of 54 acute pancreatitis patients were enrolled into the study. Patients were classified as mild or severe pancreatitis according to Ranson's criteria. There were 36 (66.7%) patients in the mild pancreatitis group (score < 6), and 18 (33.3%) patients in the severe pancreatitis group (score ≥ 6). During the first admission, blood samples were obtained for serum cytokeratin 18 levels.

RESULTS

Cytokeratin 18 levels in the mild pancreatitis group were significantly higher than in the severe pancreatitis group (271.2 ± 45.5 vs. 152.6 ± 38.2 IU/L; p < 0.001). There was a negative correlation between the disease activity score (Ranson score) and the serum cytokeratin 18 levels (p < 0.001; r = -0.724).

CONCLUSIONS

This first human study suggests that cytokeratin 18 (marker of apoptosis) might be a serological predictive marker for acute pancreatitis for disease activity.

Predictive role of acute phase reactants in the response to therapy in patients with chronic hepatitis C virus infection

BACKGROUND/AIMS

Biochemical parameters and acute-phase proteins (APPs) may provide complementary data in patients with chronic hepatitis C (CHC). We aimed to evaluate the predictive role of APPs in the response to antiviral therapy.

METHODS

Forty-five patients underwent antiviral therapy. Serum ferritin, C-reactive protein (CRP), transferrin, albumin, alpha-1 acid glycoprotein (A1AG), and alpha-2 macroglobulin (A2MG) levels were examined at the initial evaluation and at the 4th, 12th, and 48th weeks. HCV RNA levels were examined at the initial evaluation and at the 12th and 48th weeks.

RESULTS

Ferritin, transferrin, A1AG, and A2MG levels were significantly higher in the patient group (p<0.05). CRP, ferritin, A1AG, and A2MG levels were significantly increased from baseline to the 4th week (p<0.05). The responders and nonresponders to antiviral therapy had insignificantly but remarkably different levels of CRP, ferritin, transferrin, A1AG, A2MG, and alanine aminotransferase (ALT) both at the initial evaluation and at the 12th week.

CONCLUSIONS

Variations in ferritin, A1AG, A2MG, albumin, CRP, and transferrin levels are not alternatives to virological and biochemical parameters for predicting an early response to therapy in patients with CHC. However, the investigation of ALT levels and hepatitis C virus RNA in combination with acute-phase reactants may provide supplementary data for evaluating responses to antiviral therapy.

Effect of providing information to the patient about upper gastrointestinal endoscopy on the patient's perception, compliance and anxiety level associated with the procedure

BACKGROUND/AIMS

Diagnostic tests such as endoscopy are anxiety-provoking. The best intervention to reduce anxiety is to inform the patient about the procedure. Our study was conducted as a randomized controlled trial to determine the effect of providing information on the patient's perception of endoscopy, compliance with the procedure and their anxiety level associated with the procedure.

METHODS

This study included 300 patients allocated to three groups (controls, and provision of written versus verbal information). Data were collected with identification form, perception form, State/Trait Anxiety Inventory, and the Visual Analogue Scale completed by the patients and the physician regarding patient compliance. Chi-square test, paired sample t-test and one-way ANOVA tests were used for statistical evaluation of the data, and Tukey's HSD test was used for further analysis.

RESULTS

According to the results of the study, it was noted that the patients in the verbal information group responded more accurately to the questions related to the procedure. These patients experienced less pain, breathing difficulties and regret. Furthermore, they felt better during the procedure, were more satisfied, and evaluated the procedure as less difficult (p<0.05). The mean anxiety score of the patients in the verbal information group was significantly lower than of patients in the other groups (p<0.05). Compliance with the procedure was better in these patients than in the other groups, and the difference was statistically significant (p<0.05).

CONCLUSIONS

In light of our findings, we suggest that providing verbal information to patients is recommended due to its positive effects on the patient's perception, compliance and anxiety level associated with the procedure.

Serum cystatin C measurement in differential diagnosis of intra and extrahepatic cholestatic diseases

OBJECTIVE

Cystatin C is a very potent inhibitor of cysteine proteinases and, it has been clinically applied as a sensitive marker in monitoring of renal and liver functions. The aim of this study was to reveal whether cystatin C may be a useful marker for distinguishing intra- versus extrahepatic cholestasis.

MATERIALS AND METHODS

Serum cystatin C concentrations were determined by nephelometric immunoassay using N latex cystatin C kit in 53 patients with cholestatic disorder that included 18 patients with intrahepatic cholestasis , 17 patients with malignant extrahepatic cholestasis , 18 patients with benign extrahepatic cholestasis. Serum cystatin C concentration was also determined in 20 healthy volunteers.

RESULTS

Mean serum cystatin C concentration was 2.82 +/- 0.24 mg/l (SD) in patients with intrahepatic cholestasis, 2.05 +/- 0.15 mg/l in patients with extrahepatic malignant cholestasis, 1.37 +/- 0.13 mg/l in extrahepatic benign cholestatic patients and 0.93 +/- 0.24 mg/l in control group. Serum cystatin C concentrations in patients with cholestatic disease were significantly higher than those in the healthy controls (p < 0.001). Moreover, mean serum cystatin C concentration in patients with intrahepatic cholestasis was higher than those in extrahepatic cholestasis groups (p < 0.001). Serum cystatin C concentrations were significantly higher in patients with malignant xtrahepatic cholestasis than in patients with benign extrahepatic cholestasis p < 0.001). There were no correlations patients among serum cystatin C concentrations and serum levels of AST, ALT, ALP, GGT, total and conjugated bilirubin.

CONCLUSION

Our results suggested that serum cystatin C level may be a potential biochemical marker both to point out an intrahepatic origin by excluding an extrahepatic source of cholestasis in patients with jaundice and to possibly differentiate bening and malignant extrahepatic cholestatic disorders.<br />

Therapeutic effect of caffeic acid phenethyl ester on cerulein-induced acute pancreatitis

AIM: To evaluate the therapeutic role of caffeic acid phenethyl ester (CAPE) in a rat model of cerulean-induced acute pancreatitis (AP).

METHODS: Seventy male Wistar albino rats were divided into seven groups. Acute edematous pancreatitis was induced by subcutaneous cerulein injection (20 μg/kg) four times at 1-h intervals. CAPE (30 mg/kg) was given by subcutaneous injection at the beginning (CAPE 1 group) and 12 h after the last cerulein injection (CAPE 2 group). Serum amylase, lipase, white blood cell count, and tumor necrosis factor (TNF)-α levels were measured, and pancreatic histopathology was assessed.

RESULTS: In the AP group, amylase and lipase levels were found to be elevated and the histopathological evaluation showed massive edema and inflammation of the pancreas, with less fatty necrosis when compared with sham and control groups. Amylase and lipase levels and edema formation decreased significantly in the CAPE therapy groups (P < 0001); especially in the CAPE 2 group, edema was improved nearly completely (P = 0001). Inflammation and fatty necrosis were partially recovered by CAPE treatment. The pathological results and amylase level in the placebo groups were similar to those in the AP group. White blood cell count and TNF-α concentration was nearly the same in the CAPE and placebo groups.

CONCLUSION: CAPE may be useful agent in treatment of AP but more experimental and clinical studies are needed to support our observation of beneficial effects of CAPE before clinical usage of this agent.

The beneficial effect of propolis on cerulein-induced experimental acute pancreatitis in rats

BACKGROUND/AIMS

Inflammatory cytokines and oxidative stress have a central role in the pathogenesis of acute pancreatitis. Propolis is a resinous hive product collected by honeybees from various plant sources and has anti-inflammatory and anti-oxidant effects. The present work aimed to investigate the therapeutic role of ethanolic extract of propolis on a cerulein-induced acute pancreatitis model in rats.

METHODS

Seventy male Wistar albino rats were used in the study. Acute edematous pancreatitis was induced by subcutaneous cerulein injection (20 microg/kg) four times at one-hour intervals. Ethanolic extract of propolis 300 mg/kg was given subcutaneously at the beginning of the procedure (ethanolic extract of propolis-1 group) or 12 h after the last cerulein injection (ethanolic extract of propolis-2 group). Serum amylase and lipase levels, white blood cell count and serum tumor necrosis factor-alpha levels were measured and pancreatic tissue was evaluated histologically.

RESULTS

In the acute pancreatitis group, serum amylase and lipase levels were found to be elevated and the histopathological evaluation of the tissue revealed massive edema and inflammation with less fatty necrosis when compared to the sham and control groups. Serum amylase and lipase levels and edema formation were significantly decreased in the ethanolic extract of propolis-treated groups (p<0.001). In the ethanolic extract of propolis-2 group, in particular, tissue edema was improved markedly (p=0.001). Tissue inflammation and fatty necrosis were decreased with ethanolic extract of propolis treatment; however, the improvement was not statistically significant.

CONCLUSIONS

Treatment with ethanolic extract of propolis improved the biochemical and histopathological findings in a rat model of experimental pancreatitis. Although our findings suggest that ethanolic extract of propolis might be considered an effective agent for the treatment of acute pancreatitis, this notion should be supported with further experimental and clinical investigations.

Gastrocolic fistula secondary to gastric diffuse large B-cell lymphoma in a patient with pulmonary tuberculosis

Gastrocolic fistula secondary to primary gastric lymphoma is a very rare entity. On admission to outpatient clinics, it may be difficult to diagnose gastrocolic fistula, as its clinical symptoms are nonspecific. A 65-year-old man was presented with weight loss, nausea, vomiting, diarrhea, fatigue, foul-smelling eructation, and upper abdominal pain for the last 2 months. He had also been started antituberculosis drugs 2 months ago because of acid-resistant bacillus (ARB) positivity in sputum in a state hospital. Therefore, symptoms such as nausea and vomiting were attributed to the drugs used for tuberculosis. However, nausea and vomiting continued despite stopping the drugs. Upper endoscopical examination revealed a large crater on the posterior wall of gastric corpus. A large fistulous opening to the transverse colon was also identified during endoscopic examination. An upper gastrointestinal x-ray series demonstrated a fistula between the stomach and the transverse colon. Histopathological examination of the gastric biopsy was determined to be primary gastric diffuse large B-cell-type non-Hodgkin's lymphoma. In conclusion, persistent vomiting may suggest a probable gastrocolic fistula despite nonspecific clinical findings. In the literature, the present case represents the first report of a gastrocolic fistula due to gastric lymphoma in a patient with tuberculosis at its initial presentation.

Leptin levels in the differential diagnosis between benign and malignant ascites

AIM: To evaluate the role of leptin levels in the differential diagnosis of ascites.

METHODS: Ascitic leptin, TNFα and serum leptin levels were measured in 77 patients with ascites (35 with malignancies, 30 cirrhosis and 12 tuberculosis). Control serum samples were obtained from 20 healthy subjects. Leptin and TNFα levels were measured by ELISA. Body mass index (BMI) and percentage of body fat (BFM) by skin fold measurement were calculated for all patients and control groups. Peritoneal biopsy, ascites cytology and cultures or biochemical values were used for the diagnosis of patients.

RESULTS: In patients with malignancies, the mean serum and ascites leptin levels and their ratios were significantly decreased compared to the other patient groups and controls. In tuberculosis peritonitis, ascitic fluid TNFα levels were significantly higher than malignant ascites and cirrhotic sterile ascites. BMI and BFM values did not distinguish between patients and controls.

CONCLUSION: In patients with malignant ascites, levels of leptin and TNFα were significantly lower than in patients with tuberculous ascites.

Pill esophagitis caused by telithromycin: a case report

A large number of oral drugs have been reported to cause pillinduced esophagitis in the medical literature. To our knowledge, this is the first reported case in which telithromycin was the cause of pill-induced esophagitis. In this report, we describe a male patient who admitted to the hospital with dysphagia and retrosternal pain after taking telithromycin (Ketek for acute sinusitis. He had a history of swallowing the film tablet with at least a glass of water and lying down immediately after taking the drug. An upper endoscopic examination demonstrated a deep ulceration of 1 cm diameter in the middle of the esophagus surrounded by relatively normal mucosa. Lansoprazole 30 mg was started. His symptoms improved seven days after cessation of the drug. The esophagus was completely normal in control endoscopy after two weeks. Telithromycin may cause esophageal lesions; therefore, patients should be educated by physicians about the drug's side effects and should drink at least 100 ml water after swallowing the medication. Drug administration should be in the upright position.

Fascioliasis: a report of five cases presenting with common bile duct obstruction

Fascioliasis is a zoonotic infection caused by Fasciola hepatica. It is rarely seen with icterus caused by obstruction of the common bile duct. We report five patients with obstructive jaundice due to Fasciola hepatica, who were diagnosed and managed with endoscopic retrograde cholangiopancreatography (ERCP). All cases were admitted to hospital with complaints of icterus and pain in the right upper quadrant of the abdomen; their biochemical values were interpreted as obstructive jaundice. Ultrasound and computer tomography (CT) revealed biliary dilatation in the common bile duct, but did not help to clarify the differential diagnosis. ERCP showed the presence of Fasciola hepatica in the common bile duct. After removing the flukes, the symptoms disappeared and the biochemical values returned to normal. Biliary fascioliasis should be considered in the differential diagnosis of obstructive jaundice. This report confirms the diagnostic and therapeutic role of ERCP in patients with obstructive jaundice caused by biliary fascioliasis.

Demographic and clinicopathological characteristics of nonalcoholic fatty liver disease in the East-Southeastern Anatolia regions in Turkey

OBJECTIVE

To identify the demographic and clinicopathological characteristics of patients diagnosed with nonalcoholic fatty liver disease (NAFLD) and the risk factors for fibrosis based on histopathological findings in East-Southeastern Anatolia regions in Turkey.

SUBJECTS AND METHODS

The study included a total of 93 patients diagnosed with NAFLD from 5 different centers. Histopathological findings were evaluated by dividing them into four categories using Matteoni classifications. Cases with fibrosis were further evaluated using Brunt classifications.

RESULTS

The patients with a nonalcoholic fatty liver were in the 3rd and 4th decade age groups. The mean age was 38 years, 76% of the patients were male, 85% were overweight, 37% were obese, 18% had type 2 diabetes mellitus, and 80.6% had hyperlipidemia. A multiple regression analysis showed that age, type 2 diabetes mellitus, and aspartate aminotransferase (AST) levels were linked with the severity of the disease. Of the 93 patients, 55 (59.1%) had fibrosis, of which 10.8% were classified as severe. The severity of fibrosis was significantly higher in obese patients.

CONCLUSIONS

The risk factors for severity of NAFLD included advanced age, type 2 diabetes mellitus and serum AST level, while the risk factor for the severity of fibrosis was obesity.

Argon plasma coagulation in the treatment of hemorrhagic radiation proctitis

Hemorrhagic radiation proctosigmoiditis is a serious complication of pelvic radiation therapy. Pharmacotherapy is generally ineffective in the treatment of chronic radiation proctitis. Argon plasma coagulation is an effective, safe and well-tolerated therapy option for radiation proctitis. We report a case of hemorrhagic radiation proctosigmoiditis treated successfully with Argon plasma coagulation. We used argon plasma coagulation for mucosal coagulation in painting pattern set at 1.5 L/min and 60 W. After five therapy sessions with argon plasma coagulation, the patient's rectal bleeding and anemia resolved. After four months of argon plasma coagulation therapy, the patient is well and her endoscopic examination showed remarkable improvement of the vascular lesions. Blood transfusion requirement was resolved after therapy, and hemoglobin level increased from 8.2 g/dl to 11.5 g/dl. Argon plasma coagulation therapy may be useful as alternative treatment for hemorrhagic radiation proctitis. Future prospective controlled trials are necessary to confirm the efficacy of argon plasma coagulation in the treatment of radiation proctitis.

Granulocytic sarcoma of the colon and leukemic infiltration of the liver in a patient presenting with hematochezia and jaundice

Granulocytic sarcoma (GS) is an extramedullary tumor composed of immature cells of the granulocytic series known to occur in patients with myelodysplastic syndrome, chronic myelogenous leukemia, or acute myelogenous leukemia (AML). Involvement of the gastrointestinal tract is relatively rare in GS. We present an extremely rare case of GS of the colon and liver infiltration in a 60-year-old male patient with AML presenting with jaundice and hematochezia and review the literature. It should be kept in mind that hematochezia may be due to colonic involvement of GS besides thrombocytopenia which is usually encountered in patients with AML.

Effects of interferon-? therapy on cardiac function in patients with chronic hepatitis B infection

Various types of cardiovascular complications, such as myocardial infarction, cardiac arrhythmias, cardiomyopathy, and myocarditis attributed to interferon therapy have been reported. The aim of this study was to evaluate the cardiac effects of interferon-alpha (IFN-alpha) in patients with chronic hepatitis B infection. Forty-five patients with chronic hepatitis B infection (41 men and 3 women; mean age 34.2 +/- 11.5 years) were included in the study, and 10MU IFN-alpha 2b was administered three times a week for 6 months to the patients. Cardiac evaluation (detailed medical history, physical examination, electrocardiography, systolic and diastolic function parameters by echocardiography) was performed at the beginning, and at the 1st, 3rd, and 6th months of therapy. No patients had any cardiac symptoms during interferon therapy, and systolic and diastolic blood pressure and heart rate were not significantly affected (P > 0.05). None of the patients revealed cardiac rhythm disturbance on electrocardiography before or during the therapy period. No significant changes were detected in systolic (ejection fraction, fractional shortening, pre-ejection period, left ventricular ejection time, the ratio of pre-ejection period/ejection time, Q-V peak) and diastolic (E peak, A peak of transmitral flow velocity, E/A ratio, deceleration time, isovolumic relaxation time by conventional echocardiography, and E peak, A peak, deceleration time of E wave at the medial and lateral corners of the mitral annulus by tissue Doppler echocardiography) left ventricular function parameters between the beginning and the 1st, 3rd, and 6th months of therapy. The results of this study suggest that IFN-alpha therapy does not cause a significant deterioration in cardiac function in patients with chronic hepatitis B infection, and it may be used safely in patients without cardiac disease.

Effect of vitamin A against methotrexate-induced damage to the small intestine in rats

OBJECTIVE

The aim of the present study was to examine whether or not the administration of vitamin A (VA) protects against methotrexate (MTX)-induced damage to small intestinal epithelium.

MATERIALS AND METHODS

Sixty-three male Wistar albino rats, 10-12 weeks old, weighing 240-280 g, were divided into three groups: (1) controls, (2) rats receiving MTX treatment alone, and (3) rats receiving MTX plus VA treatment. A single dose of MTX (20 mg/kg MTX in 20 ml vehicle) was administered to the rats intraperitoneally. For MTX plus VA treated groups, retinol palmitate (VA) 5,000 IU/kg dissolved in 0.5 ml sunflower oil was administered by intragastric tube 3 days prior to MTX treatment and continued till the rats were sacrificed. The control group was treated with vehicle. Both control and MTX-alone groups were also treated with sunflower oil as a placebo. The rats were sacrificed on the 2nd, 4th and 6th day after MTX treatment. Tissue samples from the jejunum were taken for histopathological analysis.

RESULTS

MTX treatment induced villus shortening and fusion, epithelial atrophy, crypt loss, inflammatory infiltrate in the lamina propria, and goblet cell depletion. The pre- and post-treatment administration of VA decreased the severity of jejunal damage caused by MTX treatment.

CONCLUSION

Our results confirmed that administration of VA decreased the MTX-induced damage to the small intestine. This protective effect of VA may have clinical applications in cancer chemotherapy.

The efficacy, safety and tolerability of pantoprazole-based one-week triple therapy in H. pylori eradication and duodenal ulcer healing

OBJECTIVE

Recently, proton pump inhibitor (PPI)-based triple therapy has been recommended as a first line treatment in the eradication of Helicobacter pylori. The aim of this open, multicentre trial was to investigate the efficacy, safety, tolerability and the ulcer healing rate of a triple regimen consisting of pantoprazole 40 mg, clarithromycin 500 mg and amoxicillin 1000 mg twice daily for 7 days, in the eradication of H. pylori in patients with duodenal ulcer in Turkey.

RESEARCH DESIGN AND METHODS

H. pylori infection was assessed by histological examination and rapid urease test at baseline and 4 weeks after the completion of the therapy. Seventy-seven patients were enrolled, 5 were excluded due to various reasons and 72 completed the entire course of the trial.

RESULTS

H. pylori eradication was confirmed in 49 of these patients; the eradication rate was 68% by per-protocol analysis and 63.6% by intention-to-treat analysis. The ulcers were completely healed in 61 patients (85%) at the second endoscopic examination. Drug compliance was excellent (97.3%) and there were no serious adverse events.

CONCLUSION

Pantoprazole-based 1-week triple therapy was well tolerated and the ulcer healing rate was high (85%). Relatively low H. pylori eradication rates may be attributed to rising antibiotic resistance over recent years. A large scale, comparative study with other PPI-based regimens is warranted based on the results of this open study with the pantoprazole-based regimen.

Doxycycline-induced pill esophagitis

Pill-induced esophagitis is a complication seen in patients who use certain medications such as tetracycline and non-steroidal anti-inflammatory drugs. In this short report, we described five cases of doxycycline-induced esophagitis with endoscopic images. All of the patients were young or middle-aged women. Dysphagia or odynophagia with retrosternal pain were the main presenting symptoms in all cases. The observed injuries were at the middle third of esophagus with a normal surrounding mucosa. All patients had a history of swallowing the capsule with a small amount of water or in a recumbent position. Two patients with dysphagia were managed by intravenous fluid support and parenteral acid suppression. The symptoms were improved in 2-7 days after the ceasing of the drug and control endoscopies were completely normal in all cases after 3-4 weeks of admission. The drug-induced esophagitis is not rare with certain drugs and should be suspected in all patients presenting with chest pain and dysphagia. Physicians must warn the patients to take the pills and capsules with enough liquid and in the upright position.

Paraneoplastic cholestasis associated with prostate carcinoma

Paraneoplastic syndromes associated with prostate carcinoma are very rare. We report a patient with prostate carcinoma and cholestatic jaundice without biliary obstruction, hepatic involvement or infectious etiology. In the literature, only one case of idiopathic cholestatic jaundice with prostate carcinoma has been reported and a paraneoplastic etiology was suggested. In our case, cholestasis rapidly regressed with chemotherapy and the patient is well at six months of follow-up. Paraneoplastic cholestasis should be kept in mind in the absence of biliary tract obstruction, hepatic involvement or infectious etiology.

Oxidative stress and enzymatic antioxidant status in patients with nonalcoholic steatohepatitis

Oxidative stress is an important pathophysiological mechanism in nonalcoholic steatohepatitis (NASH). To assess whether there are relationships between oxidative stress and antioxidant enzymes in the development of NASH, we investigated oxidative stress by measuring serum malondialdehyde (MDA) and nitric oxide (NO) and antioxidant status by measuring serum glutathione (GSH), glutathione peroxidase (GSH-Px), glutathione reductase (GR), and superoxide dismutase (SOD). The study included 18 patients (13 men, 5 women; mean age 42 yr) with biopsy proven NASH and 16 healthy volunteers (10 men, 6 women; mean age 38 yr). Serum levels of MDA, NO, GSH, GSH-Px, GR and SOD were determined by spectrophotometric methods. Serum levels (mean +/- SD) of MDA (6.7 +/- 1.6 vs 2.8 +/- 1.7 nmol/ml, p 0.0001), NO (135 +/- 28 vs 113 +/- 35 mmol/L, p 0.04), GSH (919 +/- 137 vs 770 +/- 128 mmol/L, p 0.003) were increased in patients with NASH vs controls. Serum levels of GSH-Px (1063 +/- 152 vs 1000 +/- 94 U/L) and GR (47 +/- 22 vs 40 +/- 21 U/L) were not singnificantly different in the patients vs controls. However, the serum level of SOD (1.24 +/- 0.32 vs 1.51 +/- 0.37 U/ml, p: 0.04) was significantly decreased. Impaired antioxidant defense mechanisms may be an important factor in the pathogenesis of NASH. Treatment approaches that affect the antioxidant enzymes may be beneficial in patients with NASH.

Evaluation of hepatic functions and biliary dynamics in patients with liver cirrhosis by quantitative scintigraphy

BACKGROUND/AIMS

Aim of the study is to determine the changes in hepatocyte and gallbladder motor functions, and biliary dynamics in patients with liver cirrhosis.

METHODOLOGY

The study group consisted of 17 patients with liver cirrhosis (12 males, 5 females) who were diagnosed by clinical, laboratory and histopathologic findings. Control group consisted of 20 healthy persons (14 males, 6 females). Quantitative hepatobiliary scintigraphy was performed by using Tc99m-Mebrofenin i.v. and dynamic images were obtained and evaluated quantitatively by computer. Maximum excretion time of radiodiagnostic agent by liver (Tmax) and half excretion time of radio-diagnostic agent from liver (T 1/2), gallbladder filling time, gallbladder ejection fraction and the transit time of bile to duodenum were determined.

RESULTS

Mean values of Tmax was 25.76 vs. 12.40 min, T 1/2 was 37.55 vs. 23.15 min, gallbladder filling time was 53.35 vs. 30.57 min, and transit time of bile to duodenum was 39.88 vs. 25.00 min in the patients and control group, respectively. These values increased significantly in the patient group (p < 0.05) compared to controls. Mean gallbladder ejection fraction was 37.55% in the patient group and 41.84% in the control group without any statistical significance (p > 0.05). The incidence of gallbladder stone was 29.41% in the cirrhosis group and 5% in the control group (p < 0.05).

CONCLUSIONS

The quantitative hepatobiliary scintigraphy is a simple and reliable method in evaluation of hepatic functions and biliary dynamics in cirrhotic patients. Although the incidence of gallbladder stone is significantly increased in cirrhotic patients, it seems that a stone in the gallbladder does not affect the gallbladder motor functions.

Therapeutic effect of oral recombinant human granulocyte macrophage-colony stimulating factor in radiotherapy-induced esophagitis

BACKGROUND/AIMS

Radiation-induced esophagitis is one of the most important early side effects of irradiation of chest, and head and neck malignancies. This condition often leads to interruption of radiotherapy for several days. An effective treatment for reducing the incidence and severity of this complication has not yet been found. We aimed to investigate the therapeutic effect of rhGM-CSF on radiation-induced esophagitis in the patients with chest or head and neck malignancies.

METHODOLOGY

Ninety-seven patients with chest or head and neck malignancies who had not previously received radiation therapy, were treated with radiotherapy, concurrent or sequential chemoradiotherapy. Forty-eight patients who had grade 1, 2 or 3 esophagitis symptoms according to Radiation Therapy Oncology Group radiation morbidity score, underwent upper gastrointestinal endoscopy. In the patients with grade 3 esophagitis (according to Kuwahata's scoring system) rhGM-CSF was administered for 5-10 consecutive days as an oral solution.

RESULTS

Endoscopic examinations showed grade 3 esophagitis in 26 of these patients according to Kuwahata's score. Twenty-five patients with grade 3 esophagitis were given rhGM-CSF therapy. Radiotherapy was continued in 23 patients. After the rhGM-CSF therapy, esophagitis had regressed from grade 3 to grade 0 in 10 (43%), from grade 3 to grade 1 in 8 (35%), and from grade 3 to grade 2 in 3 patients (12%). Two patients (9%) did not respond to rhGM-CSF therapy. Twenty-one patients (91%) completed planned radiotherapy without interruption.

CONCLUSIONS

In patients with radiation-induced esophagitis, ulcerated esophageal mucosa healed with local granulocyte macrophage-colony stimulating factor administration in median 8 days without radiotherapy interruption.

Serum lipids, lipoproteins and apolipoproteins levels in patients with nonalcoholic steatohepatitis

GOALS/BACKGROUND

Nonalcoholic steatohepatitis (NASH) is a form of liver disease that is histologically indistinguishable from alcoholic hepatitis but occurs in persons who do not consume alcohol in excess. The objectives of this study are to measure serum levels of lipids, lipoproteins and apolipoproteins (apo AI, apo B), lipoprotein (a) [Lp (a)] in patients with nonalcoholic steatohepatitis (NASH), and to investigate the relationship with liver histology.

STUDY

The scope of this study is composed of 36 patients (27 males, 9 females) with NASH, diagnosed by biochemical liver function tests, sonographic examination of liver and liver biopsy and 32 healthy adults as a control group (22 males, 10 females). Serum lipids, lipoproteins and apo AI, apo B, and Lp (a) measurements were taken in the study group and controls, and a correlation with histopathologic findings was searched for.

RESULTS

Serum mean levels (+/- SD as mg/dl) of total cholesterol (201.05 +/- 34.48), triglyceride (225.94 +/- 156.50), and LDL-cholesterol (111.77 +/- 19.85) in patients with NASH were significantly higher than those of the control group (170.68 +/- 31.06; 138.81 +/- 49.96; 100.68 +/- 17.98; respectively) and serum HDL-cholesterol level (41.22 +/- 2.47) was less than that of the control group (45.06 +/- 8.32) (P = 0.017). The serum mean level of apo AI (151.54 +/- 30.90) in the study group was lower than that of the controls (160.62 +/- 22.11), but the difference was not significant (P = 0.17). However, the serum apo AI level in patients with liver fibrosis (140.62 +/- 35.62) was significantly lower than that of patients without liver fibrosis (164.57 +/- 25.47) (P = 0.01). The serum mean level of apo B (89.80 +/- 20.62) in the patients was significantly higher than the control group (73.25 +/- 25.39) (P = 0.004), but not correlate with liver histopathology. The serum Lp (a) levels in both the patients (13.09 +/- 9.61) and the controls (12.01 +/- 7.50) were not different (P = 0.61). Hypertriglyceridemia (above 220 mg/dL) had a positive correlation with steatosis of the liver (r = 0.333, P = 0.04) and a negative correlation with liver fibrosis (r = -0.438, P = 0.008). There was a significant negative correlation between apo AI and steatosis (r = -0.360, P = 0.03), inflammation (r = -0.364, P = 0.03) and fibrosis of liver (r = -0.418, P = 0.01). A positive correlation of serum LDL-cholesterol (r = 0.507, P = 0.002) and Lp(a) (r = 0.394, P = 0.01) concentrations with liver fibrosis was also noted.

CONCLUSIONS

Abnormalities of lipid metabolism such as the increase of serum triglyceride, cholesterol and LDL-cholesterol level and decrease of HDL-cholesterol may be the contributing factors in the development of NASH. The decrease in apo AI and the increase in LDL and Lp (a) in patients were correlated with liver fibrosis. Apo AI may be a serum marker for liver fibrosis in patients with NASH.

High prevalence of transfusion-transmitted virus infection in patients with chronic liver diseases in an endemic area of hepatitis B and C virus

OBJECTIVE

To determine the prevalence and clinical impact of transfusion-transmitted virus (TTV) DNA in patients with chronic liver diseases in the Southeast Anatolia region of Turkey where hepatitis B and C viral infections are endemic.

SUBJECTS AND METHODS

Patients diagnosed with chronic liver disease by clinical, biochemical and histologic means were enrolled in the study. Serum samples of 60 patients (19 males, 41 females) with chronic liver diseases, and of 45 healthy volunteer blood donors as a control group were collected. The chronic liver disease group consisted of 11 patients with hepatitis B, 44 with hepatitis C and 5 with chronic liver disease of unknown etiology. Presence of TTV DNA was investigated by the polymerase chain reaction. Using a scoring system histological grading of inflammation and staging of fibrosis were performed only in the chronic hepatitis C group.

RESULTS

TTV DNA was detected in 47 (78%) patients with chronic liver disease and 5 (11%) volunteers in the control group. The difference was statistically significant (p < 0.001). Ten of the 11 (91%) patients with hepatitis B, 32 of 44 (73%) of those with hepatitis C-related chronic liver disease, and 5 of 5 (100%) of the patients with cryptogenic liver disease were positive for TTV DNA.

CONCLUSION

TTV is highly prevalent in patients with chronic liver diseases in Southeast Anatolia, Turkey but no pathogenic effect attributable to TTV infection was detected.

Serum ubiquitin levels in patients with nonalcoholic steatohepatitis

BACKGROUND/AIMS

Nonalcoholic steatohepatitis is increasingly recognized as the most common liver disease in patients with elevated liver enzymes. In the pathophysiology of nonalcoholic steatohepatitis, the first step is the lipid accumulation in the liver causing steatosis, the second step involves the endotoxins, cytokines and environmental toxins causing oxidative stress and lipid peroxidation, in time leading to steatohepatitis. Ubiquitin is a molecular chaperone that plays a major role in the degradation of intracellular proteins. Ubiquitin proteasome system is also considered as a cellular defense mechanism that removes damaged proteins generated by oxidative stress. In order to search for the role of ubiquitin in the pathogenesis of nonalcoholic steatohepatitis, serum levels of ubiquitin were studied in patients with nonalcoholic steatohepatitis for the first time in the literature, to our knowledge.

METHODOLOGY

Eighteen patients with biopsy proven nonalcoholic steatohepatitis diagnosis (13 males and 5 females with a mean age of 41) and 16 healthy volunteers as a control group (11 males and 5 females, with a mean age of 38) were included in the study. Serum ubiquitin levels were studied by ELISA method.

RESULTS

The mean serum ubiquitin level (14.13 +/- 1.46 micrograms/mL) in patients with nonalcoholic steatohepatitis was significantly elevated compared to that of the control group (7.66 +/- 0.40 micrograms/mL) (p < 0.001). No correlation was found among serum ubiquitin levels and hepatic steatosis, inflammation and fibrosis.

CONCLUSIONS

Increased serum ubiquitin levels may show that the ubiquitin proteasome pathway actively participates in defending against oxidative stress in nonalcoholic steatohepatitis. Serum ubiquitin concentration may be a marker predicting the intracellular cytoprotective response against oxidative stress rather than the degree of liver damage in pathogenesis of nonalcoholic steatohepatitis. Ubiquitin proteasome system based therapies may have a place in the treatment of patients with nonalcoholic steatohepatitis in the future.

Paget's disease of the esophagus

We describe the case of a 72-year-old male patient who was suffering from Pagetoid spread to the esophageal mucosa from adenocarcinoma located in the distal esophagus and proximal stomach. Esophageal Paget's disease is rare. The histogenesis of extramammary Paget's disease has remained controversial. In the majority of cases, it originates from a primary esophageal tumor. In this report, we describe a patient who was suffering from esophageal adenocarcinoma and discuss the origin of extramammary Paget's disease in the light of the literature.

Antioxidant capacity and nitric oxide in patients with hepatic cirrhosis

This study investigated the relationship between the antioxidant capacity of blood and the serum level of nitric oxide (NO) in patients with hepatic cirrhosis. The study included 20 patients with compensated cirrhosis (group I), 30 with decompensated cirrhosis (group II), and 30 healthy controls (group III). The serum levels of NO, albumin, bilirubin, and uric acid, and the erythrocyte activity of superoxide dismutase (SOD) were measured in all groups. The mean erythrocyte SOD activity (5.94 +/- 3.21 U/mg protein) and serum NO level (25.19 +/- 8.15 micromol/L) in group I were similar to those of controls (6.86 +/- 2.47 U/mg protein and 21.67 +/- 6.51 micromol/L, respectively). However, erythrocyte SOD activity in group II was significantly lower than in groups I and III and mean serum NO level was significantly higher in group II than in groups I and III. In regard to non-enzymatic antioxidants, the mean serum albumin level was lower and the mean serum total bilirubin level was higher in group II than in groups I and III. As expected, group I had higher mean serum total bilirubin level than the control group. Correlation analysis showed that erythrocyte SOD activity in cirrhotic patients was negatively correlated with their serum levels of NO. These results suggest that disturbances of antioxidative mechanisms may diminish hepatic resistance to oxidative stress, thereby contributing to the development of fibrogenesis.

Serum levels of acute phase proteins in patients with nonalcoholic steatohepatitis

BACKGROUND/AIMS

A simple and practical method of detecting the degree of the inflammatory response during the development of nonalcoholic steatohepatitis has not been developed to date. In this study the serum levels of acute phase proteins in patients with nonalcoholic steatohepatitis and whether these levels had any relationship with histopathological findings in the liver were evaluated.

METHODS

The study included 18 patients with NASH diagnosed by liver biopsy (13 males and five females with a mean age of 44 years) and 16 healthy volunteers as a control group (11 males and five females, with a mean age of 40 years). The serum levels of C-reactive protein, C-reactive ceruloplasmin, ferritin, transferrin, alpha-1-acid glycoprotein, alpha-2-macroglobulin, alpha-1-antitripsin, albumin, haptoglobulin and lipoprotein (a) were determined by nephelometric method in both groups. In patients with nonalcoholic steatohepatitis, liver histopathology was assessed using a modified scoring system based on the classification defined by Brunt.

RESULTS

Serum C-reactive, ferritin, alpha-2-macroglobulin and ceruloplasmin concentrations in patients with nonalcoholic steatohepatitis were significantly higher than those of the control group (p=0.0001, p=0.001, p=0.007, p=0.01 respectively), but serum transferrin, albumin, haptoglobin, alpha-1-acid glycoprotein, alpha-1-antitripsin and lipoprotein (a) levels were not different. There was no difference in C-reactive protein levels regarding the degree of hepatic steatosis and inflammation and the stage of liver fibrosis. Acute phase proteins had no correlation with liver histology.

CONCLUSIONS

Measurement of serum C-reactive protein, ferritin, ceruloplasmin and alpha-2-macroglobulin levels may be useful in assessing patients at risk of nonalcoholic steatohepatitis and those with high C-reactive protein and ferritin but normal transferrin should be considered for liver biopsy.

Serum thrombopoietin levels in patients with chronic hepatitis and liver cirrhosis, and its relationship with circulating thrombocyte counts

BACKGROUND/AIMS

Thrombocytopenia in chronic liver diseases may be related to deficient production of thrombopoietin. The aim of this study was to measure serum thrombopoietin levels and to examine the relationship between serum thrombopoietin concentration, circulating platelet counts and clinical stage of the disease in patients with chronic hepatitis and liver cirrhosis.

METHODOLOGY

The study included 18 patients with chronic hepatitis, 48 with liver cirrhosis and 27 healthy volunteers. Serum thrombopoietin levels were measured by enzyme-linked immunosorbent assay. Additionally, serum albumin levels, prothrombin time, circulating platelet counts and spleen volume index were determined.

RESULTS

Mean serum thrombopoietin level (100.96 +/- 41.67 pg/mL) in the chronic hepatitis group was similar to that of the healthy group (97.60 +/- 43.99 pg/mL), however serum thrombopoietin levels in patients with liver cirrhosis (69.60 +/- 30.23 pg/mL) were lower than patients with chronic hepatitis and controls (p < 0.05 for both). In patients with liver cirrhosis, serum thrombopoietin levels were found to be decreased as the disease progressed (80.99 +/- 24.85 pg/mL in patients at Child-Pugh stage A, 67.92 +/- 39.37 in patients at stage B and 57.62 +/- 21.09 pg/mL in patients at stage C). Cirrhotic patients had increased prothrombin time (17.12 +/- 3.52 sec) and spleen volume index (94.38 +/- 26.48 cm2), and decreased serum albumin level (3.11 +/- 0.56 g/dL) and platelet counts (102,368 +/- 30,653/mm3) when compared to both chronic hepatitis and control groups. Thrombocytopenia was found in 31 (65%) of the patients with liver cirrhosis. In patients with liver cirrhosis, while there was a positive correlation between serum thrombopoietin and albumin levels (r = 0.36, p = 0.004), no correlation was found between platelet counts and serum thrombopoietin level, and spleen volume index.

CONCLUSIONS

The findings reveal that serum thrombopoietin levels are normal in patients with chronic hepatitis, but in patients with liver cirrhosis, serum thrombopoietin levels decrease, as degree of cirrhosis progresses. The impaired production of thrombopoietin may contribute to the development of thrombocytopenia in advanced stage of liver disease.

Prevalence of hepatitis G virus (HGV) infection in patients with chronic liver disease

Hepatitis G virus (HGV) may cause acute and chronic infection in humans but its role in liver injury and chronic hepatitis is unclear. In this study, the prevalence of HGV was investigated in patients with chronic liver diseases in an endemic area of hepatitis B and C virus. Sixty patients with chronic liver diseases, 11 with hepatitis B virus, 44 with hepatitis C virus and 5 patients with hepatitis of unknown etiology and 60 healthy blood donors as the control were included in the study. HGV RNA was investigated by the reverse transcription polymerase chain reaction. HGV RNA was detected in none of the patients with chronic liver diseases (0%) and only one patient (1.6%) in the control group. There was no difference between the groups. This observation indicated that the prevalence of HGV is very low in patients with chronic liver diseases and healthy people in our geographical area. The role of this novel virus in the pathogenesis of chronic liver injury seems insignificant.

Colon carcinoma with synchronous subcutaneous and osseous metastasis: a case report

Colon cancer usually metastasizes initially to regional lymphatics and later through the bloodstream. Hematogenous metastasis usually includes the liver, lungs, and brain. In colorectal cancer, osseous and/or subcutaneous metastasis without liver metastasis is a very uncommon event. We present here a case of colon adenocarcinoma, which synchronously metastasized to facial and other subcutaneous tissue and to bone within a short period after definitive therapy. Although such a pattern is uncommon, diagnostic biopsy for any new or suspicious lesion of the skin and bone scintigraphy for symptomatic patients should be done for patients with a colorectal cancer history.

Effect of cisapride on gastric emptying in patients with gastro-oesophageal reflux disease

To investigate the effect of cisapride in gastro-oesophageal reflux disease (GERD), gastric emptying time, measured using scintigraphy, and reflux symptoms were compared before and after cisapride therapy in 30 patients with endoscopically proven GERD. Gastric emptying time was also measured in 20 age-matched controls. Patients with GERD were treated with 30 mg cisapride orally three times daily for 7 days. Gastric emptying time was significantly reduced following cisapride therapy in 28 of these patients (71.6 +/- 18.1 min versus 57.9 +/- 13.9 min), although it was still longer than the gastric emptying time of the control group (i.e. 46.2 +/- 8.1 min). In addition, cisapride relieved heartburn, which is a representative symptom of GERD. These findings suggest that cisapride may be useful in treating reflux symptoms and oesophagitis in patients with GERD.