Changing trends in the etiology of liver transplantation in Turkiye: A multicenter study

Background and Aim

This study aimed to identify the indications for liver transplantation (LT) based on underlying etiology and to characterize the patients who underwent LT.

Materials and Methods

We conducted a multicenter cross-sectional observational study across 11 tertiary centers in Turkiye from 2010 to 2020. The study included 5,080 adult patients.

Results

The mean age of patients was 50.3±15.2 years, with a predominance of female patients (70%). Chronic viral hepatitis (46%) was the leading etiological factor, with Hepatitis B virus infection at 35%, followed by cryptogenic cirrhosis (24%), Hepatitis C virus infection (8%), and alcohol-related liver disease (ALD) (6%). Post-2015, there was a significant increase in both the number of liver transplants and the proportion of living donor liver transplants (p<0.001). A comparative analysis of patient characteristics before and after 2015 showed a significant decline in viral hepatitis-related LT (p<0.001), whereas fatty liver disease-related LT significantly increased (p<0.001).

Conclusion

Chronic viral hepatitis continues to be the primary indication for LT in Turkiye. However, the proportions of non-alcoholic fatty liver disease (NAFLD) and ALD-related LT have seen an upward trend over the years.

The efficacy and tolerability of glecaprevir/pibrentasvir treatment in a real-world chronic hepatitis C patients cohort

Background and Aim

The aims of the present study were to evaluate the real-life efficacy and tolerability of glecaprevir (GLE)/pibrentasvir (PIB) in the treatment of patients with chronic hepatitis C (CHC).

Materials and Methods

Between May 2019 and May 2022, 686 patients with CHC, treated with GLE/PIB combination from 21 participating centers in Turkiye, were enrolled in the study.

Results

All patients were Caucasian, and their median age was 56 years. At the start of GLE/PIB treatment, the median serum Hepatitis C virus RNA and serum alanine amino transaminase (ALT) levels were 6.74 log10 IU/mL and 47 U/L, respectively. Fifty-three percent of the patients were infected with genotype 1b, followed by genotype 3 (17%). Diabetes was the more common concomitant disease. The sustained virological response (SVR12) was 91.4% with intent-to-treat analysis and 98.5% with per protocol analysis. The SVR12 rates were statistically significant differences between the patients who were i.v. drug users and non-user (88.0% vs. 98.8%, p=0.025). From the baseline to SVR12, the serum ALT levels and Model for End-Stage Liver Disease score were significantly improved (p<0.001 and p=0.014, respectively). No severe adverse effect was observed.

Conclusion

GLE/PIB is an effective and tolerable treatment in patients with CHC.

Evaluation of the Effects of Immunosuppressive Drugs Following Liver Transplantation on Pregnancy Outcomes: A Retrospective Study

BACKGROUND

Liver transplantations can be safely performed in women of reproductive age. Women with chronic liver disease may have infertility for various reasons, although fertility returns after recovering >90% of sexual disorders following liver transplantation. The present study examined the effects of immunosuppressive drugs used by women of reproductive age undergoing liver transplantation in our clinic on pregnancy and pregnancy outcomes and evaluated mortality and morbidity in this patient population.

METHODS

Among the patients undergoing liver transplantation in our clinic between 1997 and 2020, those conceiving after liver transplantation were evaluated in the present study. Demographic data on maternal and newborn health, as well as mortality and morbidity, were recorded. Maternal transplant indications, graft type, the interval between transplantation and pregnancy, maternal age at pregnancy and the number of pregnancies, the number of living children, complications, delivery mode, immunosuppressive drugs, and blood levels were investigated.

RESULTS

A total of 615 liver transplantations (353 from a living donor, 262 from a cadaveric donor) were performed in our clinic. Furthermore, 33 pregnancies occurred in 22 women following transplantation (17 living donor liver transplantations, 5 deceased donor liver transplantations), and the data of these patients were recorded. Tacrolimus and mycophenolate mofetil were used as immunosuppressive therapy.

CONCLUSIONS

Liver transplantations can be safely performed in women of reproductive age if indicated, and these patients can be safely followed up throughout the pregnancy and during labor by a multidisciplinary team.

Complications and Long-Term Outcomes in Adult Patients Undergoing Living Donor Liver Transplantation Because of Fulminant Hepatitis

BACKGROUND

The present study investigates the complications that may occur during long-term follow-up in patients aged 18 years and older undergoing living donor liver transplantation (LDLT) in our clinic because of fulminant hepatitis.

METHODS

The study included patients aged 18 years and older with a minimum survival of 6 months who underwent an LDLT between June 2000 and June 2017. The demographic data of the patients were evaluated in terms of late-term complications.

RESULTS

Of the 240 patients who met the study criteria, 8 (3.3%) underwent LDLT for fulminant hepatitis. The indication for transplantation in patients with fulminant hepatitis was cryptogenic liver hepatitis in 4 patients, acute hepatitis B infection in 2 patients, hemochromatosis in 1 patient, and toxic hepatitis in 1 patient. Of the 240 patients, 65 (27%) undergoing LDLT underwent a liver biopsy for suspected rejection because of an elevation in liver function test results during follow-up. Histopathologic scoring was carried out according to the Banff scoring system. A diagnosis of late acute rejection was made in only 1 of the 8 patients (12.5%) who underwent LDLT for fulminant hepatitis.

CONCLUSION

Patients with fulminant hepatitis must be prepared for an LDLT, if available, while waiting for a cadaveric donor. The results of the present study suggest that LDLTs in patients with fulminant hepatitis are safe, and the outcomes are acceptable in terms of survival and complications.

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.

Endoscopic and histological characteristics of small bowel tumors diagnosed by double-balloon enteroscopy

BACKGROUND/AIMS

Double-balloon enteroscopy (DBE) allows for the diagnoses and treatment of small bowel tumors (SBTs). This study aimed to evaluate the utility of DBE for the diagnosis and treatment of SBTs.

METHODS

Patients diagnosed with SBTs who underwent DBE were included in this study. According to their endoscopic appearances, they were categorized as polyps or masses, and according to their histological characteristics, they were categorized as benign or malignant SBTs.

RESULTS

A total of 704 patients were retrospectively analyzed, and 90 (12.8%) were diagnosed with SBTs. According to their endoscopic appearance, 48 (53.3%) had polyps and 42 (46.7%) had masses. Additionally, 53 (58.9%) and 37 (41.1%) patients had malignant and benign SBTs, respectively, depending on their histological characteristics. Patients diagnosed with polyps were younger than those diagnosed with masses (p<0.001). Patients diagnosed with benign SBTs were younger than those diagnosed with malignant SBT (p<0.001). Overall, histological diagnosis was determined using DBE in 73 (81.1%) patients.

CONCLUSION

DBE is a useful method for diagnosing SBTs. Additionally, the histological type of the lesion can be determined using DBE.

Prevalence of Gastrointestinal Symptoms and Clinical Outcomes in Hospitalized Coronavirus Disease 2019 Patients: A Single-Center Study from Turkey

BACKGROUND

In patients with coronavirus disease 2019, the gastrointestinal symptoms have been reported increasingly in addition to the respiratory system symptoms. The studies show that the prevalence of gastrointestinal system symptoms and how the gastrointestinal system contributes to the severity and prognosis of the disease is still not clear. This study aims to find the prevalence of gastrointestinal symptoms and the correlation between the gastrointestinal symptoms and the clinical results in hospitalized patients diagnosed with coronavirus disease 2019.

METHODS

This study retrospectively analyzes patients diagnosed with coronavirus disease 2019 and hospitalized in the pandemic unit between March 2020 and August 2020 and compares their demographic and clinical characteristics, laboratory and radiologic findings, coronavirus disease 2019 treatments received, the clinical course of the disease, and the gastrointestinal symptoms.

RESULTS

In our study, we included 322 patients diagnosed with coronavirus disease 2019 and hospitalized; 39 patients (12.1%) were admitted to the hospital with at least one gastrointestinal symptom (nausea and vomiting, diarrhea, abdominal pain, and the loss of taste). Nausea and vomiting are the most common gastrointestinal symptoms with a prevalence of 7.1%, followed by diarrhea with 2.8%, the loss of taste with 2.2%, and abdominal pain with 1.5%. The mean age and D-dimer levels of the patients showing gastrointestinal symptoms were lower than those who did not have any gastrointestinal symptoms. We did not find a significant correlation between the presence of the gastrointestinal symptoms and the severity of the disease, treatment received, risk of acute respiratory distress syndrome and septic shock, admission to the intensive care unit, the need for mechanical ventilation, the mortality rate or the length of hospitalization in the medical floor or the intensive care unit.

CONCLUSION

In this study, we observed that 12.1% of coronavirus disease 2019 patients apply to the hospital due to gastrointestinal symptoms. Furthermore, the gastrointestinal symptoms do not seem to affect the severity and the course of the disease, it is important to identify coronavirus disease 2019 patients showing unusual symptoms such as the gastrointestinal symptoms at an early stage to protect healthcare professionals from infection risk.

Double Balloon Enteroscopy in a Pregnant Woman with Peutz-Jeghers Syndrome

Peutz-Jeghers syndrome is an autosomal dominant disorder characterised by multiple hamartomatous polyps and muco-cutaneous pigmentation. Most polyps are found in the small intestine, especially in the jejunum. Enteroscopy with polypectomy is a reliable method to prevent polyp-related complications. A pregnant woman, who was diagnosed as a case of Peutz-Jeghers syndrome with a history of intestinal resection, was admitted to our clinic. Termination was recommended to the patient due to the possibility of polyps, causing obstruction during pregnancy. She underwent double balloon enteroscopy in the second trimester. Large polyps that could cause intussusception were removed and post-polypectomy bleeding was successfully controlled. This procedure was the first double balloon enteroscopy during pregnancy, reported in the literature. The procedure should be performed by experienced endoscopists, who can cope well with the complications in expert centres, as the procedure carries a high risk. Key Words: Double baloon enteroscopy, Pregnancy, Peutz-Jeghers syndrome, Polyps.

Recommendations for Hepatitis B Immunoglobulin and Antiviral Prophylaxis Against Hepatitis B Recurrence After Liver Transplantation

The combination of hepatitis B immunoglobulin and potent nucleos(t)ide analogs after liver transplantation is considered as the standard of care for prophylaxis against hepatitis B virus recurrence. However, the recommended doses, route of administration, and duration of HBIG administration remain unclear. Moreover, hepatitis B immunoglobulin-free prophylaxis with potent nucleos(t)ide analogs has shown promising disease outcomes in preventing hepatitis B virus recurrence. The current recommendations, produced by the Turkish Association for the Study of the Liver, Acute Liver Failure and Liver Transplantation Special Interest Group, suggest a reduced need for hepatitis B immunoglobulin administration with effective long-term suppression of hepatitis B virus replication using potent nucleos(t) ide analogs after liver transplantation.

Evaluation of colon mucosa using screening colonoscopy and flexible spectral imaging color enhancement in patients with long lasting ulcerative colitis

Aim

To determine which flexible spectral imaging color enhancement (FICE) channel best visualizes colon mucosa in ulcerative colitis (UC) and to compare FICE imaging with standard imaging.

Methods

The study enrolled patients with ulcerative colitis in remission who had inflammatory bowel disease for at least 8 years. All patients underwent screening colonoscopy. The entire colon, especially the suspicious areas in terms of dysplasia, were imaged with standard endoscopy and FICE. Random and target biopsies were obtained. Histopathological diagnosis was made and image patterns were evaluated. Seven endoscopists evaluated normal, colitis, and polyp images obtained with FICE.

Results

One hundred and twenty-three colon segments were evaluated and 1831 images were obtained from 18 patients. A total of 1652 images were FICE and 179 were standard images. Separate FICE images were obtained for normal colon mucosa, polypoid lesions, and colitis areas. Normal colon mucosa was best visualized using the second, sixth, and ninth FICE channel; polyps using the third, seventh, and ninth channel; and colitis using the second, third, and ninth channel. When all images were analyzed, the second and ninth channel were significantly better than the other channels. A total of 584 biopsies were obtained, including 492 (84.2%) random biopsies and 92 (15.7%) target biopsies. Random biopsies detected no dysplasia, but target biopsies detected low-grade dysplasia in three diminutive polyps.

Conclusion

FICE was not significantly better at dysplasia screening than the standard procedure, but it effectively detected diminutive polyps and evaluated surface patterns without using magnification. FICE might contribute to the assessment of inflammation severity in patients with UC in clinical remission. However, more extensive studies are necessary to confirm these findings.

Real-world efficacy and safety of Ledipasvir + Sofosbuvir and Ombitasvir/Paritaprevir/Ritonavir ± Dasabuvir combination therapies for chronic hepatitis C: A Turkish experience

BACKGROUND/AIMS

This study aimed to evaluate the real-life efficacy and tolerability of direct-acting antiviral treatments for patients with chronic hepatitis C (CHC) with/without cirrhosis in the Turkish population.

MATERIAL AND METHODS

A total of 4,352 patients with CHC from 36 different institutions in Turkey were enrolled. They received ledipasvir (LDV) and sofosbuvir (SOF)±ribavirin (RBV) orombitasvir/paritaprevir/ritonavir±dasabuvir (PrOD)±RBV for 12 or 24 weeks. Sustained virologic response (SVR) rates, factors affecting SVR, safety profile, and hepatocellular cancer (HCC) occurrence were analyzed.

RESULTS

SVR12 was achieved in 92.8% of the patients (4,040/4,352) according to intention-to-treat and in 98.3% of the patients (4,040/4,108) according to per-protocol analysis. The SVR12 rates were similar between the treatment regimens (97.2%-100%) and genotypes (95.6%-100%). Patients achieving SVR showed a significant decrease in the mean serum alanine transaminase (ALT) levels (50.90±54.60 U/L to 17.00±14.50 U/L) and model for end-stage liver disease (MELD) scores (7.51±4.54 to 7.32±3.40) (p<0.05). Of the patients, 2 were diagnosed with HCC during the treatment and 14 were diagnosed with HCC 37.0±16.0 weeks post-treatment. Higher initial MELD score (odds ratio [OR]: 1.92, 95% confidence interval [CI]: 1.22-2.38; p=0.023]), higher hepatitis C virus (HCV) RNA levels (OR: 1.44, 95% CI: 1.31-2.28; p=0.038), and higher serum ALT levels (OR: 1.38, 95% CI: 1.21-1.83; p=0.042) were associated with poor SVR12. The most common adverse events were fatigue (12.6%), pruritis (7.3%), increased serum ALT (4.7%) and bilirubin (3.8%) levels, and anemia (3.1%).

CONCLUSION

LDV/SOF or PrOD±RBV were effective and tolerable treatments for patients with CHC and with or without advanced liver disease before and after liver transplantation. Although HCV eradication improves the liver function, there is a risk of developing HCC.

The COVID-19 pandemic: Clinical practice advice for gastroenterologists, hepatologists, and liver transplant specialists

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a novel acute infectious disease that has rapidly reached staggering pandemic proportions. This review addresses gastroenterologists, hepatologists, liver transplant (LT) specialists, and health-care professionals working in the field of liver diseases and liver transplantation. It has been written based on a limited number of publications, recommendations of national and international liver and organ transplantation societies, and experiences of patients with COVID-19 around the world. The purpose of this review is to provide information addressing questions and concerns about COVID-19, to reveal the effects of the novel disease on patients with chronic liver disease and LT recipients, and to share information about ways in which this pandemic will affect clinical practices. We, the Turkish Association for the Study of the Liver (TASL), would like to remind you that this text is actually not a practical guide. It is imperative to act according to the standards set by health-care institutions and the Ministry of Health, Republic of Turkey.

The validity and reliability study of the University of California, Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract (UCLA SCTC GIT) 2.0 questionnaire for the Turkish society

BACKGROUND/AIMS

To translate the University of California, Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract (UCLA SCTC GIT) 2.0 questionnaire from English to Turkish and to validate it.

MATERIALS AND METHODS

UCLA SCTC GIT 2.0 was translated into Turkish using the translation-retranslation method. The available Turkish GIT 2.0 and the Short Form 36 (SF-36) were administered to 97 Turkish-speaking patients with systemic sclerosis (Ssc). Internal consistency reliability and structural validity were assessed by analyzing the correlations between the UCLA SCTC GIT 2.0 and the SF-36 scales. Internal consistency was determined by calculating Cronbach's alpha. For evaluation of reliability, the questionnaire scale was repeatedly applied to a subgroup of patients with a 2-week interval, and the intraclass correlation coefficient (ICC) was calculated. The Spearman's correlation coefficients between the GIT and the SF-36 scores were calculated.

RESULTS

A group of 97 patients with Ssc with a mean age of 55.37±11.35 years and a female predominance (87.6%) were included in the study. The Cronbach's alpha value for the UCLA SCTC GIT 2.0 scale was 0.894. ICC was 0.821 (p=0.000). The scale showed acceptable reliability, with the exception of the diarrhea subscale (alpha=0.356). There was a moderate correlation between the total GIT score and the Short Form 36 (SF-36) subscales. All of the items in the scale were included in the validity analysis owing to their reliability.

CONCLUSION

The Turkish GIT 2.0 scale showed good internal consistency, high reliability, and an acceptable validity.

Type I cardiorenal syndrome in patients with acutely decompensated heart failure: the importance of new renal biomarkers

OBJECTIVE

Type 1 cardiorenal syndrome (CRS) is an acute renal failure in patients with acute decompensated heart failure with an incidence of 24% to 45%. The aim of our study was to investigate the significance of new renal biomarkers to predict type 1 CRS.

PATIENTS AND METHODS

The study included 111 patients with acute decompensated heart failure diagnosed at the Istanbul Medical Faculty Emergency Department between 2014 and 2016, and 24 healthy volunteers. All urine samples were stored at -80°C after centrifugation. Samples were run according to the instructions of TIMP-2, ILGF-7, KIM-1, and IGFBP-7 ELISA kits. Diuretic treatments were then administered with intravenous administration of at least 80 mg furosemide per day. Follow-up biochemical and spot urine specimens were taken after 72 hours. For statistical analysis, SPSS version 21.0 statistical software was used. Significance was evaluated at p<0.05.

RESULTS

The baseline creatinine level was measured as 1.33 ± 0.39 mg/dL in the heart failure group. It was seen that 67% (75) of the patients had increased creatinine levels and developed type 1 CRS. ILGF-7, TIMP-2, and (ILGF-7 * TIMP-2) values were significantly higher in patients with cardiorenal syndrome when we separated the two groups as patients with and without cardiorenal syndrome (0.40 (0.25-0.71), p1: 0.049/2.40 (1.42-3.70), p2: 0.003/1.15 (0.29-2.43), p3: 0.001).

CONCLUSIONS

Renal tubular markers reveal promising developments in the pathophysiology of cardiorenal syndrome in light of recently obtained data. Renal tubular biomarkers may have the potential to be a predictor of heart failure and cardiorenal syndrome.

Survival Outcomes After Liver Transplantation in Elderly Patients: A Single-Center Retrospective Analysis

AIM

This study aims to evaluate survival rates in elderly patients after liver transplantation (LT) and to analyze the factors associated with mortality.

PATIENTS AND METHODS

Our study includes 535 patients over the age of 18 who had undergone LT in our clinic between June 2004 and January 2018. Data were collected prospectively and scanned retrospectively. Data concerning the patients' age, sex, LT indication, Child-Turcotte-Pugh score, Model for End-Stage Liver Disease score, presence of hepatocellular cancer (HCC), coexisting disease, LT types, and post-transplant survival were investigated. The patients were grouped under 2 categories (18-59 years of age and 60 years of age and over) and were compared in terms of their characteristics. In patients aged 60 and over, the causes of mortality and related factors were investigated.

RESULTS

The study included 535 patients, 458 (85.6%) of whom were between 18 and 59 years of age and 77 (14.4%) were over 60 years of age. The median follow-up period was 86.7 (1 to 247) months. The elderly group's survival rate was significantly lower than that of the younger group (P = .002). In elderly patients, survival rates of 1, 3, 5, and 10 years were 67.4%, 56.4%, 53.8%, and 46.1%, respectively.

CONCLUSION

In elderly patients, factors that increase post-LT mortality require thorough consideration. Equally important is the physiological status of the candidates for transplantation. Correct patient selection in the preoperative stage and good postoperative care can provide successful survival results in elderly patients.

C-reactive protein may be a prognostic factor for the whole gastroenteropancreatic neuroendocrine tumor group

BACKGROUND

Long non-coding RNAs (lncRNAs) are a kind of single-stranded RNA of more than 200 nucleotides in length and have no protein-coding function. Amounting studies have indicated that lncRNAs could play a vital role in the initiation and development of cancers, including gastric cancer (GC). Considering the crucial functions of lncRNAs, the identification and exploration of novel lncRNAs in GC is necessary.

AIM

To identify independent prognostic markers for the whole gastroenteropancreatic neuroendocrine tumor (GEP-NET) group.

METHODS

Ninety-three patients diagnosed with GEP-NETs within a specified period were included in this study. Patient data were retrospectively analyzed. The relationships between all independent variables and 5-year survival status calculated during the follow-up period (months) were assessed. In addition, the relationships between the independent variables were investigated.

RESULTS

When 5-year survival rate was compared, a statistically significant relationship between the age at diagnosis, male gender, tumor size, tumor stage, liver and/or distant metastasis, and tumor grade determined by the Ki-67 level and mitotic count, and the level of C-reactive protein (CRP), was observed. The mean survival (overall survival) of the study group was 102.5 ± 6.3 (SD) mo. The percentages of 1, 3 and 5-year survival were 90%, 72%, and 61%, respectively. In 63 of 93 patients, Ki-67 and the mitotic count determined the same grade. The Ki-67 levels in 29 patients and the mitotic count in only 1 patient were in the higher grade. The risk of death increased by 4% for every 1 year increase at the diagnosis age and was 2.0-fold higher for male patients, 3.0-fold higher for G3 according to the mitotic count, 3.7-fold higher for G3 according to the Ki-67 level, 12.7-fold higher for cases with tumor stage 3 or 4 by a 1 cm increase in the ratio of 9% in tumor size, and 6.1-fold higher for patients with liver metastasis for every 1 mg/dL increase in the ratio of 1.5% in CRP level. There was a significant difference between pancreatic and stomach NETs in favor of stomach tumors in terms of survival.

CONCLUSION

Tumor site, stage, grade and Ki-67 level affected patient survival, and it was observed that CRP affected disease progression (particularly if it was > 20 mg/dL). However, a relationship between surgical resection of the lesion and survival was not shown. Larger scale prospective studies are required to determine whether CRP level may be a poor prognostic factor for the entire GEP-NET group.

The Analysis of Posthepatectomy Liver Failure Incidence and Risk Factors Among Right Liver Living Donors According to International Study Group of Liver Surgery Definition

AIM

There is a well-known risk of the emergence of hepatic failure in living donor transplant cases on whom are performed a right donor hepatectomy (RDH). There are different prevalence ratios in literature on this phenomenon. In our study, we aim to depict the prevalence of hepatic failure and risk factors in our cases regarding the most recent description criteria related to hepatic failure.

PATIENTS AND METHODS

We included right liver donor hepatectomy cases who fit the donor evaluation algorithm at the Dokuz Eylul University Liver Transplantation Unit between the period of June 2000 and September 2017. The patients were evaluated regarding preoperative data. Liver failure was defined according to the International Study Group of Liver Surgery (ISGLS) criteria. We also included statistical analysis of risk factors that are potentially related to liver failure.

RESULTS

We included a total of 276 patients. In 27 (9.7%) patients, we observed posthepatectomy liver failure (PHLF). In 26 (9.4%) patients, we observed Grade A liver failure; in 1 (0.3%) patient, we observed Grade B liver failure. We did not observe any Grade C hepatic failure. In patients with hepatic failure, we observed a significantly longer period of hospitalization (P = .007). Old age (odds ratio = 1.065, 95% confidence interval, 1.135-29.108, P = .035) and preoperatory red blood cell (RBC) transfusion (odds ratio = 5.749, 95% confidence interval, 1.019-1.113, P = .005) were shown as independent risk factors for PHLF.

CONCLUSION

Posthepatectomy liver failure is a vital complication of RDH. The risk can be decreased by careful selection of donor candidates. Elderly donor candidates and intraoperative RBC are independent risk factors for PHLF.

Liver Transplant in Patients with Primary Sclerosing Cholangitis: Long-Term Experience of a Single Center

OBJECTIVES

Primary sclerosing cholangitis is a chronic inflammatory disease of the intrahepatic and extrahepatic bile ducts. More than half of the patients will face end-stage liver disease and require liver transplant. Here, we describe the long-term outcomes of liver transplant in patients with primary sclerosing cholangitis at our center.

MATERIALS AND METHODS

For this retrospective, observational study, we investigated all patients who underwent liver transplant for primary sclerosing cholangitis between January 2005 and June 2013 at the Dokuz Eylul University Hospital. Patient data were obtained from hospital records. Our inclusion criteria were patients over 18 years old and diagnosed with primary sclerosing cholangitis.

RESULTS

Of 11 patients included the study, 6 (54.5%) were male and 5 (45.5%) were female. Mean age was 40.6 ± 11.0 years (range, 23-60 y). All patients had cirrhosis due to primary sclerosing cholangitis. With regard to Child-Turcot-Pugh classification, 2 patients (18.2%) were classified as having Child-Turcot-Pugh A cirrhosis, 7 patients (63.6%) were classified as having B cirrhosis, and 2 patients (18.2%) were classified as having C cirrhosis. Mean Modified End-Stage Liver Disease score was 17.5 ± 6.1 (range, 7-25). Cholangiocarcinoma was not detected in explant pathologic examinations. Primary sclerosing cholangitis recurrence developed in 2 patients (18.1%). Three patients (27.2%) died during the follow-up period.

CONCLUSIONS

Liver transplant is a good therapeutic option for primary sclerosing cholangitis with satisfactory long-term outcomes. Liver transplant should be reserved for patients with end-stage liver disease and other conditions that significantly impair quality of life.

De Novo Malignancies After Liver Transplantation: A Single Institution Experience

OBJECTIVES

Our objective was to analyze characteristics, risk factors, and incidence of de novo malignancies after liver transplant.

MATERIALS AND METHODS

The hospital records of 557 patients who underwent liver transplant were analyzed from the point of de novo malignancy development. We evaluated the demographic features and survival of these patients retrospectively.

RESULTS

The research covered 429 patients, 9 (2%) of whom developed de novo malignancy. All of these patients were male (100%), and their mean (SD) age was 51.33 (4.69) years (range, 45-65 y). Indications for transplant included alcohol related in 4 cases, chronic hepatitis B in 2 cases, chronic hepatitis B and C in 1 case, chronic hepatitis B and D in 1 case, and chronic hepatitis C and alcohol-related cirrhosis in 1 case. The mean (SD) time from transplant to cancer diagnosis was 63.41 (37.10) months (range, 17-122 mo). The types of tumors were lung cancer, lymphoma, neuroendocrine tumor of lung, nasopharyngeal cancer, and squamous cell carcinoma of the skin. Seven cases received chemotherapy with or without radiotherapy. Two cases received surgery and radiotherapy. One patient underwent surgical treatment. One patient died before treatment was started.

CONCLUSIONS

In recent years, improvements in surgical techniques and immunosuppressive therapies have helped prolong survival of patients who undergo liver transplant. However, this also has led to a rise in the incidence of long-term complications such as de novo malignancy. These patients are more likely to develop de novo malignancy than the general population, for which chronic immunosuppression is identified as a major risk factor. Early diagnosis and treatment of de novo malignancies can help obtain better prognosis and higher survival rates in these patients.

Are N-acetylcysteine and adalimumab effective for non-alcoholic steatohepatitis?

Due to the lack of effective medical treatment for non-alcoholic steatohepatitis (NASH), we aimed to evaluate new treatment options. In particular, our goal was to investigate and compare the effects of N-acetylcysteine (NAC) and Adalimumab treatment on tumor necrosis factor alpha (TNF-α) and oxidative stress during the development of NASH in a rat model of the disease. Our study included a total of 35 female Wistar albino rats that were divided into 5 groups of 7 each, and evaluated over a 6 week period. One group received a normal diet, while the other four groups received a methionine and choline deficient (MCD) diet. One of the groups receiving the MCD diet did not take any medicine, while the other three were administered NAC, adalimumab, or a NAC/adalimumab combination therapy. NASH was successfully established in the MCD diet group. Levels of TNF-α were effectively suppressed in the three groups that received therapy. Even though adalimumab significantly enhanced suppression of TNF-α, the NASH score was suppressed to a more statistically significant extent in the groups receiving NAC. Our study showed that TNF-α and oxidative stress play an important role in NASH pathogenesis. The antioxidant agent, NAC, was found to be superior to the anti-TNF agent, Adalimumab, in the improvement of total NASH score. Although these drugs did not prevent the development of NASH, it was shown that they mildly reverse the NASH histopathology score, suggesting improvement of and overall liver function.

A comparison of the effects of infliximab, adalimumab, and pentoxifylline on rats with non-alcoholic steatohepatitis

BACKGROUND/AIMS

Non-alcoholic steatohepatitis (NASH) lacks effective medical treatment. Since tumor necrosis factor alpha (TNF-α) plays an important role in NASH pathogenesis, we aimed to investigate drugs affecting TNF-α as possible treatment options during the development of NASH.

MATERIALS AND METHODS

A total of 35 rats were divided into five groups and evaluated over a 6 week period. One group received a normal diet alone or in combination with the administration of infliximab, adalimumab or pentoxifylline.

RESULTS

NASH was successfully established in the MCD diet group. Levels of TNF-α were effectively suppressed in the three groups that received anti-TNF agents. No statistically significant differences were observed between the three agents in terms of the histological NASH score.

CONCLUSION

Our study showed that the anti-TNF agents infliximab, adalimumab, and pentoxifylline effectively suppress TNF-α. Although these drugs did not prevent the development of NASH, they were able to slightly reverse the NASH histopathology score and positively affect liver function tests.

Diagnostic and therapeutic efficacy of double-balloon endoscopy in patients with small intestinal diseases: single-center experience in 513 procedures

BACKGROUND/AIMS

Double-balloon endoscopy (DBE) is a technique that enables the evaluation and treatment of small intestinal diseases. The aim of the study was to evaluate the indications, therapeutic interventions, complications, and safety and to describe the experience with DBE in Turkish patients.

MATERIALS AND METHODS

Four hundred twenty consecutive patients undergoing DBE were included in our study. Demographic features, indications, diagnostic findings, therapeutic interventions, complications, and technical aspects of the procedure were recorded. A total of 513 DBEs were carried out.

RESULTS

In all, 420 patients underwent a total of 513 DBE procedures (369 (72%) oral and 144 (28%) anal). The most common clinical indications were obscure bleeding (26%), abdominal pain (25.2%), anemia (20%), chronic diarrhea (10.5%), and inflammatory bowel diseases (5.2%). A proper diagnosis was obtained or confirmed in 222 of 420 patients (52.3%). Ulcers/erosions (23.6%), vascular lesions (8.1%), and polyps/tumors (7.4%) represented the most common endoscopic findings. Perforation occurred in one patient as a complication after polypectomy. No major complications due to sedation occurred.

CONCLUSION

Double-balloon endoscopy is effective for the diagnosis and treatment of small intestinal diseases. Therapeutic interventions carried out by DBE seem to be useful and safe.

The efficacy and safety of tenofovir in the prevention of hepatitis B virus recurrence following liver transplantation

BACKGROUND/AIMS

In this study, a tenofovir disoproxil fumarate (TDF) + hepatitis B immunoglobulin (HBIG) regimen was compared with lamivudine (LAM) + HBIG to determine the efficacy and safety of TDF in the prevention of hepatitis B virus (HBV) recurrence following liver transplantation (LT).

MATERIALS AND METHODS

Thirty-six patients, 18 treated with TDF+HBIG (TDF group) and 18 with LAM+HBIG (LAM group), were evaluated retrospectively over a median 36-month follow-up in the Liver Transplantation Outpatient Unit of Dokuz Eylül University after having an LT. In the TDF group, TDF treatment was initiated in six patients due to resistance to LAM, in one patient due to relapse, in three patients to prevent relapse, and in eight patients due to de novo hepatitis. In the LAM group, LAM therapy was initiated in two patients due to de novo hepatitis and in 16 patients to prevent relapse.

RESULTS

In the TDF group, an increase of greater than 0.5 mg/dL in creatinine values was observed in two patients. In the LAM group, creatinine values did not increase to greater than 0.5 mg/dL. No cases of acute renal failure associated with TDF or LAM, mild or serious adverse events, or HBV recurrence were observed among the patients. Glomerular filtration rates (GFRs) of these patients were calculated with a modification of renal disease (MDRD) formulation. There was no significant difference (p<0.05) in the GFRs between the two groups.

CONCLUSION

The results of this study, after a 36-month follow-up period, were encouraging and demonstrated that TDF therapy is safe and efficacious in treating HBV-positive organ transplant patients. However, patients should be monitored carefully in terms of renal function. Given the limited experience with TDR in LT, this study is of importance due to its long follow-up period.

The association between insulin resistance and hepatic fibrosis in patients with chronic hepatitis C: an observational, multicenter study in Turkey

BACKGROUND/AIMS

To evaluate the association between insulin resistance and hepatic fibrosis in patients with chronic hepatitis C.

MATERIALS AND METHODS

A total of 104 chronic hepatitis C patients were included in this non-interventional, open-label, observational, multicenter, cross-sectional study conducted at 20 gastroenterology clinics in Turkey. The primary end point was the correlation between stage of hepatic fibrosis and insulin resistance evaluated via the homeostasis model of assessment-insulin resistance index. Confounders of hepatic fibrosis and insulin resistance were the secondary end points.

RESULTS

The mean age of patients was 52.8 years; 65.4% were female. Type 2 diabetes was present in 6.8% and insulin resistance noted in 38.0% of patients. Further, 45.7% of the patients had mild (A0/A1) and the remaining had moderate/severe (A2/A3) hepatic necroinflammatory activity. Patient distribution according to Metavir fibrosis stage was as follows: F0/F1 (57.0%); F2 (6.5%); F3 (23.7%); and F4 (12.9%). A univariate analysis revealed significant positive correlations between Metavir fibrosis stage and insulin resistance (r=0.297; p=0.007). Logistic regression analysis showed that significant predictors of insulin resistance were high alanine transaminase levels (odds ratio, 0.97; 95% confidence interval, 0.944-0.997) and liver fibrosis stage (odds ratio, 0.114; 95% confidence interval, 0.021-0.607).

CONCLUSION

Our findings revealed significant associations between insulin resistance and hepatic fibrosis.

Liver Transplantation in Cases with Acute Liver Failure

Background

Acute liver failure (ALF) is a rare, life-threatening clinical condition that is characterized by severe hepatocellular necrosis, jaundice, coagulopathy and encephalopathy. The aim of this study was to evaluate patients who underwent liver transplantation at Dokuz Eylul University of Medicine Faculty (DEUMF) due to ALF.

Materials and methods

The patients who underwent liver transplantation at DEUMF due to ALF were evaluated retrospectively.

Results

All of the liver transplantations performed in this study were successful; toxicity was the major cause of ALF in these patients (84%).

Conclusion

Results of this study may not be generalizable to all of Turkey since the patients included in this study were only from one region. However, our study is in accordance with others that show that liver transplantation is a very safe and effective method for the treatment of ALF.

How to cite this article

Yalçin M, Bengİ G, Akarsu M, İnek T, Astarcioşlu İ. Liver Transplantation in Cases with Acute Liver Failure. Euroasian J Hepato-Gastroenterol 2015;5(2):80-82.

The validity and reliability of "The liver disease symptom index 2.0" for Turkish society

BACKGROUND/AIMS

Chronic liver diseases have been shown to adversely affect the quality of life. Standardized tools for patient assessment are of great importance for treatment and follow-up of these patients. In this study, we aimed to determine the validity and reliability of the Liver Symptom Index 2.0 (LDSI 2.0) for Turkish society, for use in other studies and in daily clinical practice.

MATERIALS AND METHODS

A total of 308 patients with chronic liver disease attending to the outpatient liver clinic of the Department of Gastroenterology, Faculty of Medicine, Dokuz Eylül University between September 2011 and May 2012 were included in this study. A sociodemographic data questionnaire, the LDSI 2.0 comprising 24 items, and the Short Form-36 (SF-36) were completed by the participating patients. After 6 weeks, these tools were re-administered to a total of 115 patients. After obtaining the required permissions, LDSI 2.0 was translated into Turkish using the translation/re-translation method.

RESULTS

Of the 308 participants, 160 (51.9%) were male and 184 (43.1%) were female, with an average age of 48.67±13.31 years. Of all cases, 70.5% had viral hepatitis. The average Child-Pugh score was 5.9±1.2, and the average Model For End-Stage Liver Disease (MELD) score was 10.2±3.2. The assessment tool comprised the following sub-items: itching, joint pain, abdominal pain, sleepiness, worry, appetite, depression, fear, jaundice, memory, personality, financial status, use of time, sexual desire, and sexual activity. For more than 50% of the patients, worry (68.8%), depression (65.3%), joint pain (62.3%), itch (56.5%), sleepiness (54.2%), memory problems (53.6), and sexual problems (50%) were present. The internal coefficient of consistency (Cronbach alpha coefficient) was 0.908, which indicates a very high level of consistency. The correlation coefficient for the intraobserver test/re-test reliability was 0.746 (p<0.000), which denotes a significant and good level of reliability. The construct validity between each sub-item of the tool and sub-items of SF-36 was assessed using Spearman's correlation test, which showed a weak to moderate correlation (<0.04 and 0.4-0.7) in the reverse direction.

CONCLUSION

Our study findings provide supportive evidence of the reliability of the assessment tool. Its validity is similar to the original construct validity and was confirmed in our sample. Therefore, it was concluded that LDSI 2.0 was an appropriate tool for daily clinical use and research purposes. Simultaneous use of this life-quality assessment tool and SF-36 will enable a comprehensive but practical assessment of our patients.

Prevalence and risk factors for obesity after liver transplantation: a single-center experience

BACKGROUND

The study of weight gain after transplantation and its associated factors is necessary to propose strategies to prevent and treat this problem.

OBJECTIVES

This study aims to investigate factors affecting the development of obesity after liver transplantation (LTx).

PATIENTS AND METHODS

Medical records of 343 liver transplantation cases, which were followed between January 2001 and January 2010 at Dokuz Eylul University, were retrospectively analyzed. Patient pre-liver transplantation height, body weight, body mass index (BMI) measurements, as well as changes in body weight at the beginning, 6 months, 12 months, and 5 years post-transplantation were observed. BMI measurements with records of immunosuppressive therapies were obtained.

RESULTS

The study was carried out with the records of 226 patients. 151 patients (66.8%) were male; 75 (33.2%) were female. The mean age was 46.19 ± 10.2 years. 123 of these liver transplants were performed from living donors, while 103 were from cadaveric donors. The causes of liver transplantation were hepatitis D virus (HDV) infection (28%), hepatitis B virus (HBV) infection (24%), hepatitis C virus (HCV) infection (24%), alcoholic liver disease (9%), cryptogenic liver disease (9%), autoimmune hepatitis (4%), and other (2%). In this study, the prevalence of obesity was 21% at the end of the second year, decreasing to 14% by the end of the fifth year. The mean BMI gradually increased during the follow-ups, reaching 25.1 kg/m² and 26 kg/m² six months after liver transplantation and at the end of the first year, respectively (P < 0.002). Obesity developed in 18.2% of post-transplant patients who were receiving a calcineurin inhibitor (CNI). Regarding the development of obesity after transplantation, no statistically significant difference was found between patients using cyclosporine (CsA) and tacrolimus (TAC) (P = 0.07). Six months after liver transplantation, the mean body weight gain in the groups receiving steroids and not receiving steroids were 4.71 kg and 2.7 kg, respectively (P = 0.03). In the post-transplant period, there was no significant difference in patients who had received TAC and CsA for development of diabetes mellitus (DM), hypertension (HT), or hyperlipidemia (HL) (P = 0.30).

CONCLUSIONS

Obesity prevalence before and after liver transplantation was comparable. Education of obese patients prior to surgery and recommendation of medical nutrition therapy should be appropriate. Similar medical care for the non-obese subjects could prevent increase in obesity prevalence. Non-corticosteroid immunosuppressive agents had no significant effect on the development of weight gain and obesity. Avoiding the use of long-term steroid therapy and obesity education are the key measures for preventing obesity after liver transplantation.

Changes of Some Hormones Levels in Patients With Hepatitis B Virus-Related Chronic Liver Disease

Background

The purpose of the study was to evaluate some of the hormones in patients with chronic liver disease and cirrhosis.

Methods

The men patients with chronic hepatitis B (Group 1), liver cirrhosis secondary to hepatitis B (Group 2), were included in this study. Additionally, a control group of healthy volunteers (Group 3) was formed. We investigated serum levels of Follicle-stimulating hormone (FSH), Luteinizing hormone (LH), Total testosterone (T. TES), Free-testosterone (F. TES), Estradiol (E2), Androstenedione (ANDR), Dihydroepiandrosterone (DHEA), Progesterone (PPOGES), Prolactin (PRL), Sex hormone binding protein (SHGB) were measured by radioimmunoassay and chemiluminescent immunoassay methods.

Result

A total of 73 patients with chronic liver disease and cirrhosis were included in the study. Patients were grouped as cirrhosis (n = 28), chronic hepatitis B (n = 41) according to the type of their chronic liver disease. Serum F.TEST level in patient groups (group 1, group 2) was found to be lower than control group (P = 0.045, P = 0.047). Serum LH value was found to be higher in patient group (group 2) than control group (P = 0.048). Serum estradiol was higher in the group 2 compared to the control group (P = 0.046).

Conclusions

The described disturbances of some of the observed hormones (LH, E2, F. TES) are complex, particularly in their relationship by which the clinical picture of the hepatitis B related cirrhotic patients and chronic liver disease can be explained.

Double-balloon endoscopy in patients with Peutz-Jeghers syndrome

BACKGROUND/AIMS

Peutz-Jeghers syndrome is a rare hereditary syndrome characterized by mucocutaneous pigmentation and hamartomatous polyps of the gastrointestinal tract, especially in the small intestine. Double-balloon endoscopy is a new endoscopic technique that enables both endoscopic visualization of the entire small bowel and therapeutic interventions in a single procedure. In this study, we evaluate the efficacy and safety of double-balloon endoscopy for both treatment and surveillance of patients with Peutz-Jeghers syndrome.

MATERIALS AND METHODS

We retrospectively evaluated 7 consecutive patients who were referred to Dokuz Eylül University, Gastroenterology Department, with the diagnosis of Peutz-Jeghers syndrome between 2007 and 2010.

RESULTS

Patients with Peutz-Jeghers syndrome (M/F: 5/2) underwent a total 31 double-balloon endoscopy procedures: 21 by the oral route, 9 by the anal route, and 1 intraoperatively. All of the patients had a history of laparotomy and small bowel resection due to complications such as invagination and ileus. In 7 patients, we found a total of 110 polyps ≥10 mm in diameter (10-100 mm) and polypectomies were performed in all of them. The only complication was a bleeding after polypectomy, which was controlled by sclerotherapy. In 1 patient, because of the intraabdominal adhesions due to past laparotomies, polypectomy was done by intraoperative endoscopy. In 2 of our patients, we made surveillance colonoscopies, found new polyps in the small intestine, and performed polypectomies.

CONCLUSIONS

Double-balloon endoscopy is an effective and safe endoscopic technique, and represents a milestone for both treatment and surveillance of patients with Peutz-Jeghers syndrome. Polypectomies made in the small intestine might decrease the complication rate due to these polyps and the need for surgery.

Evaluation of early atherosclerosis in patients with inflammatory bowel disease

BACKGROUND

Data regarding early atherosclerosis and inflammatory bowel disease are limited and conflicting results are present.

AIMS

The purpose of this study was to evaluate serological and sonographical evidence of subclinical vascular involvement in patients with inflammatory bowel disease.

METHODS

Thirty-nine patients with inflammatory bowel disease (20 Crohn's disease, and 19 ulcerative colitis patients) and 31 healthy controls were consecutively enrolled in the study. Flow mediated dilatation of the brachial artery and intima media thickness assessments of the common carotid artery were measured sonographically. Soluble CD40 ligand levels were evaluated. Crohn's disease activity index and modified Truelove-Witt's criteria were also noted.

RESULTS

Age, sex distribution, serum lipids, smoking status, and intima media thickness of the common carotid artery were similar between the inflammatory bowel disease patients and controls (p > 0.05). However, both endothelium dependent and independent flow mediated dilatation values were significantly impaired in the inflammatory bowel disease group compared with healthy controls (p < 0.05). Erythrocyte sedimentation rate, C-reactive protein and soluble CD40 ligand values were significantly increased in inflammatory bowel disease patients compared with controls (p < 0.05), and soluble CD40 ligand was negatively correlated with flow mediated dilatation (r = -0.3, p < 0.05). Flow mediated dilatation was significantly predicted from the concentrations of C-reactive protein and soluble CD40 ligand.

CONCLUSION

Functional atherosclerosis is present in inflammatory bowel disease before early structural changes occur in vasculature. Higher sCD40L may indicate worse vascular outcome for IBD.

Comparison of Milan and UCSF criteria for liver transplantation to treat hepatocellular carcinoma

AIM: To assess the validity of the Milan and University of California San Francisco (UCSF) criteria and examine the long-term outcome of orthotopic liver transplantation (OLT) in patients with hepatocellular carcinoma (HCC) in a single-center study.

METHODS: This study is a retrospective review of prospectively collected data. Between 1998 and 2009, 56 of 356 OLTs were performed in patients with HCC. Based on pathological examination of liver explants, patients were retrospectively categorized into 3 grou-ps: Milan + (n = 34), Milan -/UCSF + (n = 7) and UCSF - (n = 14).

RESULTS: Median follow-up period was 39.5 (1-124) mo. The 5-year overall survival rates in the Milan +, Milan -/UCSF + and UCSF-groups were 87.7%, 53.6% and 33.3%, respectively (P < 0.000). Within these groups, tumor recurrence was determined in 5.8%, 14.3% and 40% of patients, respectively (P < 0.011). Additionally, the presence of microvascular invasion within the explanted liver had a negative effect on the 5-year disease free survival (74.7% vs 46.7%, P < 0.044).

CONCLUSION: The Milan criteria are reliable in the selection of suitable candidates for OLT for the treatment of HCC. For cases of OLT involving living donors, the UCSF criteria may be applied.

[A real-time PCR assay for the quantification of hepatitis B virus DNA and concurrent detection of YMDD motif mutations]

Monitoring therapy in chronic hepatitis B patients receiving lamivudine therapy, is done by two different assays; determination of viral load and genotypic resistance. These methods are labor intensive and time consuming. It was aimed to develop an assay to quantitate hepatitis B virus (HBV) DNA in serum and detect YMDD (thyrosine, methionine, aspartate, aspartate) motif mutations in the same run. The assay was based on real-time polymerase chain reaction (Rt-PCR) with YMDD-specific hybridization probes. Determination of YMDD motif was done by melting temperature analysis. External standard curve was used for quantifying viral DNA, which was generated by standard sera (VQC S2220) including HBV-DNA between concentrations of 1000 to 3 million copies/ml. The assay was compared with commercial quantitative kit (Artus HBV RG PCR; Qiagen, Germany), commercial line prob assay (INNO-LiPA HBV DR v1.0; Innogenetics, Belgium) and direct DNA sequencing method. Thirty-eight serum samples obtained from 20 chronic hepatitis B patients (7 female, 13 male; age range: 27-70 years) treated with only lamivudine and were negative for HIV and HCV antigen and antibodies were tested in the study. The analytical sensitivity of the assay was found as 200 copies/ml, with a dynamic range of 1 x 103 to 3 x 107 copies/ml. PCR efficiency of the in-house assay was found to be 1.98. Comparison of log10 HBV-DNA concentrations determined by the in-house and commercial quantitative kits showed a significant correlation (r= 0.681). Melting temperature (Tm) analysis was used for the YMDD motif determination and found to be 59.86°C for YMDD, 56.34°C for YVDD and 55.10°C for YIDD. The results of the in-house assay, DNA sequencing and LiPA were concordant in samples with homogeneous virus population, and in-house assay could also detect the major type of YMDD motif in mixed viral populations The Rt-PCR method which was developed in this study is a rapid, accurate and reproducible method for quantifying HBV-DNA and detecting the predominant YMDD motif in the same run in two hours duration. It was concluded that this method may be a convenient tool for monitoring HBV-infected patients receiving lamivudine treatment.

Ectopic pancreas presenting with intractable diarrhea: case report

Ectopic pancreas is an uncommon congenital anomaly, which is usually found incidentally in clinical practice. It presents with nonspecific gastrointestinal symptoms like epigastric pain and dyspepsia and rarely with the clinical findings of obstructive jaundice or intestinal obstruction, or it may mimic gastrointestinal system cancer. Herein, we describe a case of ectopic pancreas in the duodenum, which was the cause of the intractable diarrhea. In our patient, upper gastrointestinal endoscopy and endoscopic ultrasonography revealed a 1.5 cm submucosal lesion, which was umbilicated centrally with a normal in appearance overlying mucosa. Endoscopic biopsy of the lesion was normal. Pathological examination of the lesion after surgical excision was compatible with ectopic pancreas. After total excision of the lesion, the clinical findings of the patient normalized. Ectopic pancreas presenting with diarrhea has not been reported previously in the literature.

Does glucagon like peptide-2 receptor expression have any effect on the development of human colorectal cancer?

BACKGROUND/AIMS

Glucagon like peptide-2 may play an important role in human colon cancer and polyp development because of its proliferative and antiapopitotic effects especially in colon. In this study, we investigated the role of human glucagon like peptide and it's receptor in development of human colorectal carcinogenesis.

MATERIAL AND METHODS

The study includes 30 patients in colon cancer group and 20 patients in colonic polyp group who have been diagnosed by endoscopic and pathologic examination in Dokuz Eylül University, Department of Gastroenterology within 2 year-period. For comparison biopsies were taken from normal appearing colonic mucosa of the same patient. The cancer, polyp and normal colon mucosa samples were stained with glucagon like peptide receptor antibody by immunohistochemical method.

RESULTS

Glucagon like peptide 2 receptor positivity of colon cancer patients was 20 % (6/30) in focal cytoplasmic coloration while it was 0 % in colonic adenomas and 100 % in enteroendocrine cells of normal colonic mucosa. Statistically significant differences were found by the comparison of colonic polyp and normal colonic tissue (p=0.000), colonic cancer and normal colonic tissue (p=0.000) and colonic polyp and cancer tissues (p= 0.023).

CONCLUSION

Glucagon like peptide-2 receptor expression in colonic adenomas was not detected in human in contrary to the study on mice. Our study suggested that Glucagon like peptide-2 receptor expression is not a factor in adenoma-cancer pathogenesis. More studies are needed on this subject with more facts and different methods.

A patient with nonfunctional pancreatic neuroendocrine tumor and incidental metachronous colon carcinoma detected by positron emission tomography: case report

Pancreatic neuroendocrine tumors constitute about 2% of all gastrointestinal neoplasms. Approximately half of the pancreatic euroendocrine tumors are nonfunctional. Due to lack of specific symptoms, most patients with nonfunctional pancreatic neuroendocrine tumors present with locally advanced or metastatic disease. Second primary malignancies are seen very rarely in these patients. Colon carcinoma ranks third in frequency among primary sites of cancer in both men and women in western countries. Presence of a metachronous colon adenocarcinoma in a patient with nonfunctional pancreatic neuroendocrine tumor has not been reported before. We present a patient who had an asymptomatic mass in the head of the pancreas, detected by ultrasonography in 1996. The patient did not consent to operation. In 2002, after the diagnosis of an unresectable, nonfunctional pancreatic neuroendocrine tumor, interferon alpha- 2b and octreotide were started. A year after biological treatment, he refused further treatment. In 2004, during the evaluation of dissemination of the asymptomatic disease, positron emission tomography revealed a high uptake by the descending colon despite the failure of other imaging methods. After surgery for operable colon carcinoma, the patient received chemotherapy and biological therapy for both tumors. Since 2005, he has been doing well without any further treatment thus far. In conclusion, computerized tomography/magnetic resonance imaging and octreotide scintigraphy may be insufficient to show disseminated disease and asymptomatic second primary malignancies. Therefore, positron emission tomography is a valuable promising option for the evaluation of gastroenteropancreatic neuroendocrine tumors and concomitant or metachronous malignancies. Lifelong follow-up by a multidisciplinary oncology team is needed so that a long-term survival can be achieved with integrated multimodal systemic treatment approaches.