Primary malignant melanoma of the esophagus

Primary malignant melanoma of the esophagus (PMME) comprises only 0.1–0.2% of all malignant esophageal tumors. PMME tumors are highly aggressive and metastasize early via hematogenic and lymphatic pathways. Treatment outcome is poor because the cancer has often advanced at the time of diagnosis. Inoperability, unsuccessful treatment with radiotherapy and chemotherapy in advanced tumors and metastases have contributed to its poor prognosis. Here, we present the endoscopic features, endoscopic ultrasonography findings and management of a PMME case.

Anticoagulant therapy and Budd-Chiari syndrome: is it successful?

BACKGROUND/AIMS

Anticoagulant therapy is an accepted treatment for Budd-Chiari syndrome (BCS). However, the natural course of untreated patients is unclear. We aimed to evaluate the efficacy of anticoagulant therapy on survival in BCS.

METHODOLOGY

Between 1995 and 2007, 45 patients diagnosed with BCS based on the clinical, biochemical, radiological and histological findings were retrospectively evaluated with respect to underlying disease, therapeutic interventions, complications and overall outcome. Complications and survival during the follow-up period were compared in between anticoagulant treated and untreated cases.

RESULTS

Mean patient age was 34.4 +/- 11.8 years and 46.7% (21) of them were male. Median followup time was 24 months (6-132); 8.9% of patients were diagnosed as acute, 31.1% as subacute and 60% as chronic BCS according to disease duration. Centrilobular necrosis was found in 16 of 36 biopsy performed patients. Etiological factors were detected in 60% of patients and 40% of them were cryptogenic. Twenty four of them received anticoagulant therapy, the remaining 21 were followed-up with supportive medical therapy. Five patients who had shunt operation were excluded for survival analyses. Complications were similar between treated and untreated cases (p>0.05). There was a positive correlation between survival and centrilobular necrosis (r=0.376, p=0.037). The mean survival periods were 95.5 months (%95 CI 73-117 months) and 72.5 months (%95 CI 42-103 months) in anticoagulant treated and untreated patients, respectively (p>0.246).

CONCLUSION

Most patients with BCS are admitted to hospital at the chronic stage and more than half of them have underlying thrombotic risk factor. In our study, no beneficial effects of anticoagulant therapy were observed on the survival and complications of liver disease.

Is portal hypertensive enteropathy an important additional cause of blood loss in portal hypertensive patients?

OBJECTIVE

Recently, mucosal changes of small bowel were defined by developing new imaging techniques including capsule endoscopy (CE) in portal hypertensive patients. However, the clinical impact of these changes is unknown. In this study, we aimed to determine the additional cause of blood loss in portal hypertensive patients.

MATERIAL AND METHODS

A total of 444 portal hypertensive patients, hospitalized in our clinic between 2005 and 2007, were evaluated. Patients with obscure bleeding were enrolled to this prospective case-control study. CE was performed in 21 patients who met inclusion criteria. Gastroscopy, colonoscopy and computerized tomography/small bowel enema were performed in all patients.

RESULTS

Fourteen cirrhotic and seven noncirrhotic portal hypertensive patients were enrolled to this study. Mean age of patients was 47.9±15.6 years, and 13 of 21 were male. Small bowel varices were found in 7 patients (1 active bleeding) and other mucosal abnormalities in 10 patients (vascular ectasia, erosion and edema, 1 active bleeding). Although two of them were normal, jejunal malignant mass was found in two patients (1 active bleeding). Of 21 patients, 19 (90.5%) patients had portal hypertensive abnormalities (including varices). However, ileal varices rate was 57.1% (4 patients) in noncirrhotic portal hypertensive patients and 21.4% (3 patients) in cirrhotics.

CONCLUSION

Ninety percent of patients had portal hypertensive abnormalities in small bowel and one-third of them had small bowel varices. Small bowel varices and vascular ectasia were the main causes of obscure bleeding in portal hypertensive patients.

Electron microscopic findings in non-alcoholic fatty liver disease: is there a difference between hepatosteatosis and steatohepatitis?

BACKGROUND AND AIMS

Non-alcoholic fatty liver disease has long been accepted as benign; however, recent evidence suggests that the disease may progress to cirrhosis and hepatocellular carcinoma, although the natural course of the disease is still unclear. This study was designed to comparatively evaluate electron microscopic features of non-alcoholic fatty liver (NAFL) and non-alcoholic steatohepatitis (NASH).

METHODS

Quantitative and semi-quantitative ultrastructural evaluations were performed on liver biopsies from 23 patients, 10 with NAFL and 13 with NASH.

RESULTS

No statistically significant difference was noted between NAFL and NASH patients in ultrastructural features of hepatocytes including megamitochondria, intramitochondrial crystalline inclusions, mitochondrial matrix granules, foamy cytoplasmic appearance, electron-lucent and glycogen-containing nuclear regions, lipofuscin granules, or an increased frequency of vesicles containing electron-dense material in peribiliary Golgi zone; however, the mitochondrial diameter was significantly higher in the NASH patients. Intercellular distance and microvilli between hepatocytes, collagen and electron-dense material accumulation in the space of Disse, electron-dense material accumulation and microvillus density in bile canaliculi did not differ significantly between the groups.

CONCLUSIONS

Our data show that, although NAFL and NASH can be distinguished by their distinct light microscopic features, ultrastructural characteristics are similar, which suggests that NAFL may also have the potential to progress to fibrosis and cirrhosis like NASH.

Response to hepatitis B vaccination in patients with celiac disease

Abnormal immune response to gliadin, genetic, and environmental factors play a role in the pathogenesis of celiac disease (CD). Non-responsiveness to hepatitis B virus (HBV) vaccination is related to genetic features. Certain human leukocyte antigen (HLA) genotypes are more prevalent among non-responders to HBV vaccination. There is also a strong relationship between CD and these HLA genotypes. This study investigates the relationship between CD and non-responsiveness to HBV vaccination, with an emphasis on genotypic co-incidence. No statistically significant difference was noted between the ages and gender of CD patients and control subjects. Baseline serum IgA, IgM, and IgG levels of all CD patients were normal. Responsiveness to HBV vaccination was observed in 17 (68%) CD patients and all (100%) control subjects (P = 0.006). In conclusion, CD should also be sought in unresponders to HBV vaccine who are not immunosuppressed.

Combined effects of vitamin C, vitamin E, and sodium selenate supplementation on absolute ethanol-induced injury in various organs of rats

In this study, the effect of combination of vitamin C (ascorbic acid), vitamin E (alpha -tocopherol), and selenium (sodium selenate) on ethanol-induced liver and intestine injury in rats was investigated. The ethanol-induced injury was produced by the administration of 1 ml of absolute ethanol to each rats. Animals received vitamin C (250 mg/kg), vitamin E (250 mg/kg), and sodium selenate (Se) (0.5 mg/kg) for 3 days; 1 h after the final antioxidant administration, they were sacrificed. Lipid peroxidation and glutathione levels, catalase (CAT), lactate dehydrogenase (LDH), superoxide dismutase (SOD), and glutathione peroxidase (GP(x)) activities were determined in liver and intestine tissues. Myeloperoxidase (MPO), aspartate transaminase (AST), alanine transaminase (ALT), alkaline phosphatase (ALP), gamma-glutamyltransferase (GGT) were determined in liver tissue. Also, CAT activity, urea, creatinine, uric acid, and total lipid levels were determined in serum samples. In the ethanol group, serum urea, creatinine, uric acid, and total lipid levels; liver and intestine LDH; liver MPO, AST, ALP, ALT, and GGT activities; and liver and intestine LPO levels increased, whereas serum CAT activity, liver and intestine GSH levels, and CAT, SOD, and GP(x) activities decreased. On the other hand, treatment with vitamin C, vitamin E, and Se reversed these effects. As a result of these findings, we can say that the combination of vitamin C, vitamin E, and selenium has a protective effect on ethanol-induced changes in lipid peroxidation, glutathione levels, and antioxidant enzyme activities in liver and intestine tissues, and in some serum parameters of rats.

The effects of rosiglitazone, metformin, and diet with exercise in nonalcoholic fatty liver disease

Our aim was to evaluate effects of metformin, rosiglitazone, and diet with exercise in nonalcoholic fatty liver disease. Forty-seven patients (mean age, 44+/-10 years; 17 female) whose ALT levels had been high for at least 6 months and with hepatosteatosis detected by liver biopsy and/or USG were enrolled in this study. Of these, 12 were treated with 850 mg/day metformin (group 1), 11 with 4 mg/day rosiglitazone (group 2), and 24 with diet and exercise (group 3) for 1 year. ALT normalization at months 6 and 12 was accepted as treatment response. Liver biopsy was performed in all patients in groups 1 and 2 before treatment and 12 patients (4 in group 1, 8 in group 2) after treatment; but in group 3 it was performed only in patients who approved this procedure (12 patients). Body mass index did not change in groups 1 and 2, but it decreased significantly in group 3 (30+/-3 to 28+/-2 kg/m(2)) at month 12. Treatment response rate was 33.3, 54.5, and 54.2% in groups 1, 2, and 3, respectively, at month 6. This rate was 22.2, 37.5, and 41.2 in groups 1, 2, and 3, respectively, at month 12. Rate of steatosis and stage of fibrosis did not change after treatment. Diet with exercise seems to be superior to metformin and rosiglitazone. Decreasing treatment response at month 12 compared to month 6 may be due to fluctuations of ALT levels. Treatment response should be evaluated histologically.

What is the reason of elevated alanine aminotransferase level in HBeAg negative patients with low viremia: NAFLD or chronic hepatitis?

BACKGROUND AND STUDY AIMS

Increased alanine aminotransferase (ALT) levels with negative hepatitis B virus (HBV) DNA by hybridization is a common problem in Turkey where is a mild endemic region. We aimed to evaluate the causes of elevated ALT levels in patients who are negative for hepatitis B e antigen (HBeAg) and HBV DNA (by hybridization) for at least 6 months.

PATIENTS-METHODS

Forty-nine patients were enrolled in this study. Histological changes [histological activity index (HAI), and the extent of fibrosis] were assessed according to the Knodell scoring system and steatosis were graded by Brunt's classification for NAFLD in all patients.

RESULTS

A mean age of the patients was 34.9 +/- 12.1 years (16-70). 43 (87.8%) of them were male. Mean ALT level was 95 +/- 39.7 IU/L (50- 258). Hyperglycemia (>100 mg/dL) and hyperlipidemia were found in 12 and 24 patients, respectively. Hepatic steatosis (7 patients grade 1; 5 patients grade 2; and 7 patients grade 3), ground-glass hepatocyte, chronic hepatitis, and Wilson disease were found in liver biopsy in 38.8%, 32.6%, 26.6%, 2%, respectively. Mean HAI was 6.5 +/- 3.6 (4-12) in chronic hepatitis. Seven patients (53.9%) were in stage 1 and 2 while 6 patients (46.1%) were in stage 3 and 4.

CONCLUSIONS

Nonalcoholic fatty liver disease is the most common cause of elevated ALT levels in HBeAg negative/HBV DNA negative patients. Chronic hepatitis B was found in 26.6% of these patients.

Treatment of hepatic hydrothorax with terlipressin in a cirrhotic patient

Hepatic hydrothorax is a complication of cirrhosis that is uncommon and difficult to treat. Diuretic therapy, thoracentesis, transjugular intrahepatic portosystemic shunt and liver transplantation are the main therapeutic options. Here, we report on a 47-year-old man with decompensated liver cirrhosis related to hepatitis B and D virus infections and who had complications of hepatic hydrothorax and hepatorenal syndrome. In this case, the hepatic hydrothorax, which was refractory to thoracic tube drainage and octreotide treatment, could be controlled with 5 days of terlipressin therapy associated with albumin. Terlipressin administration resulted in both improvement in renal function and successful resolution of hepatic hydrothorax. Splanchnic vasoconstrictor agents that reduce splanchnic blood flow, increase both central volume and effective renal blood flow. Thus they improve renal function. In our case, terlipressin, known to be beneficial in hepatorenal syndrome, was also effective in the treatment of hepatic hydrothorax probably by similar mechanisms. This is the first case in the literature.

Risk factors for the transmission of hepatitis C virus infection in the Turkish population

The risk factors for the transmission of hepatitis C virus (HCV) infection varies substantially between countries and geographic regions. The aim of this investigation was to determine the risk factors which may be involved in the transmission of HCV infection in the Turkish population. This study included patients who were admitted to the Department of Gastroenterohepatology, Istanbul Medical Faculty, Istanbul University, between 1996 and 2002 and found to be anti-HCV positive during hospitalization or during follow-up as outpatients. All patients were asked about risk factors for HCV transmission including transfusion, history of operation, hospitalization, hemodialysis, intravenous drug use, suspected sexual contact, tattooing, acupuncture, dental procedures, manicure and pedicure, blood brotherhood rituals, perinatal risk factors, common circumcision rituals, and history of abortion. In our study, total of 320 patients with anti-HCV seropositivity were involved. The numbers and percentages of male and female patients were 139 (43.4%) and 181 (56.6%), respectively. The mean age of the patients was 49.7+/- 12.4 years (range: 18-73 years). HCV-RNA was found to be positive in 297 (92.8%) patients. The most common risk factor was a history of surgery (305; 98%), and the second most common was blood transfusion (123; 39.7%). The numbers and percentages of patients for the other risk factors were as follows: dental procedure, 86 (27.5%); abortion, 66 (21.2%); long-term hospitalization, 37 (11.6%); hemodialysis, 31 (10%); history of jaundice, 15 (4.6%); history of intravenous drug abuse, 10 (3.1%); history of suspected sexual contact, 5 (1.5%); history of manicure and pedicure, 4 (1.2%); history of occupational transmission, 3 (0.9%); history of tattooing, 2 (0.6%); history of acupuncture, 2 (0.6%); circumcision in a common circumcision ritual, 1 (0.3%); and percutaneous needle puncture, 1 (0.3%). None of the patients had a history of blood brotherhood ritual or perinatal transmission. Only one risk factor was detected in 73 (22.8%) patients, two risk factors were detected in 122 (38.2%) patients, three risk factors were detected in 78 (24.5%) patients, and four risk factors were detected in 39 (12.2%) patients, however, in 8 (1.6%) patients no risk factors could be found. In Turkey, the most common risk factor for the transmission of HCV infection is surgery, which can be preventable.

Pneumatic balloon dilatation in primary achalasia: the long-term follow-up results

BACKGROUND/AIMS

Pneumatic dilatation is a safe and most effective treatment for achalasia. We analyzed the long-term results of pneumatic dilatation in primary achalasia by objective and subjective findings.

METHODOLOGY

Pneumatic dilatation was performed in patients that were diagnosed with primary achalasia in our manometry laboratory between 1993-1999 years. We evaluated patients with clinical, radiologic, endoscopic and manometric results before treatment. Mean esophageal diameters on the level of the lower esophageal sphincter and middle esophagus were measured by barium esophagograms. The patients were clinically reevaluated after one week and barium esophagograms were repeated one month later after dilatation. Clinical examination, endoscopy and manometry were done at 1, 3, 6 and 12 months and repeated yearly for follow-up period. A statistical comparison of pre- and posttreatment on the frequency of dysphagia, radiological diameter of the esophagus and manometric data was performed using unpaired t tests and chi2 tests.

RESULTS

Pneumatic dilatation was performed on 50 adult patients with a mean age 41.42+/-18.07 years. A single dilatation was successful in forty patients (80%) and two to three dilatations were performed in ten (20%) patients. The median number of dilatations was 1.26. In the postdilatation period, mean short-term (< 1 year) and long-term (2-7 years) clinical improvement was 82.8% and 66.85% respectively. The mean diameter of the esophagus was regressed to 26.51+/-7.69 mm from 36.66+/-11.23 mm (p<0.001) and the mean diameter of the lower esophageal sphincter was increased to 8.38+/-3.12 mm from 2.58+/-1.13 mm (p<0.001) with pneumatic dilatation. The mean pretreatment pressure of lower esophageal sphincter was 41.14+/-11.34 mmHg and these values were 18.79+/-7.85 mmHg (p<0.001), 13.18+/-9.53 mmHg (p<0.001) in the 1st, and 5th years of the posttreatment period, respectively. The mean pressure of the lower esophageal sphincter was 31.78+/-8.91 mmHg in nonresponder patients during the posttreatment period; there was no significant difference prior to pneumatic dilatation (p>0.1). Surgical operation was performed on 5 patients (10%), who had no benefit from pneumatic dilatation.

CONCLUSIONS

Pneumatic dilatation is an effective procedure in the treatment of primary achalasia during the short- and long-term period. Treatment evaluation can possibly be made objectively with radiographic and manometric alterations of esophagus that occurred after pneumatic dilatation.

The protective effect of vitamin C, vitamin E and selenium combination therapy on ethanol-induced duodenal mucosal injury

In this study, the effect of a combination of vitamin C, vitamin E and selenium on ethanol-induced duodenal mucosal damage in rats was investigated morphologically and biochemically. The duodenal mucosal injury was produced by oral administration of 1 mL of absolute ethanol to each rat. Animals received vitamin C (250 mg/ kg), vitamin E (250 mg/kg) and selenium (0.5 mg/kg) for 3 days and absolute ethanol 1 hour after last antioxidant administration and were sacrificed 1 hour after absolute ethanol. Extreme degeneration in intestinal mucosa of rats given ethanol was observed morphologically. In addition, an increase in neuronal nitric oxide synthase immunoreactive areas was observed in the rats of the group given ethanol. On the other hand, a normal morphological appearance and a decrease in neuronal nitric oxide synthase immunoreactive areas were detected in the rats given ethanol+vitamin C+vitamin E+ selenium. In the group to which ethanol was administered, an increase in serum cholesterol and a decrease in serum albumin levels were determined. On the other hand, in the group to which ethanol+vitamin C+vitamin E+selenium were administered, serum cholesterol value decreased, and the serum albumin level increased. As a result, we can say that the combination of vitamin C, vitamin E and selenium has a protective effect on ethanol-induced duodenal mucosal injury.

Blue rubber bleb nevus syndrome associated with consumption coagulopathy: treatment with interferon

The blue rubber bleb nevus syndrome (BRBNS) is a rare vascular malformation syndrome with cutaneous and visceral lesions frequently associated with serious, even fatal bleeding. No systemic therapy is currently available. We report here a case with disseminated skin and gastrointestinal venous malformations and findings of disseminated intravascular coagulation that was treated with interferon beta. The disseminated intravascular coagulation manifestations were cleared with the treatment. The regression of the coagulopathy in our patient led us to think that the use of interferon beta in BRBNS might be beneficial.

Ulcerative colitis: analyses of 116 cases (do extraintestinal manifestations effect the time to catch remission?)

BACKGROUND/AIMS

Evaluation of clinical, demographic and epidemiologic features of ulcerative colitis and therapy response of these patients.

METHODOLOGY

Retrospectively, 116 patients (64.7% female) were enrolled in this study. Mean age and mean follow-up period were 36+/-16, 5+/-2 years, respectively.

RESULTS

The most common anatomic involvement was pancolitis (60.3%) and the others were as follows: left side 25%, rectum 13.8% and ileum (backwash ileitis) 0.9%. Extraintestinal manifestations were observed in 42.2% of patients (sacroiliitis 12%, primary sclerosing cholangitis 7.6%, pyoderma gangrenosum 2.4%, peripheral arthropathy 1.6%, autoimmune hepatitis 1.6%, steatosis 12.9%, gallstone 0.8%, perianal fistulas 0.8%, sagittal sinus thrombosis 0.8%, psoriasis 0.8%). Multiple extraintestinal manifestations were observed (primary sclerosing cholangitis + pyoderma gangrenosum) in 2 patients. Colonic perforation due to toxic megacolon was observed in only one patient during follow-up period. The mean period for remission was 3.7 months in 72% of patients with pancolitis by the treatment of 5-aminosalicylic acid (5-ASA) (2-3 gr/day) + methylprednisolone (1 mg/kg/day) +/- (for maintenance of remission) azathioprine (AZT) (1.5-2 mg/kg/day); 3.7 months in 72% of left-sided colitis by 5-ASA +/- corticosteroid enemas +/- methylprednisolone (1 mg/kg/day) +/- (for maintenance of remission) AZT (1.5-2 mg/kg/day) and 3.7 months in 62.5% of patients with distal colitis by 5-ASA (p.o. +/- enema) +/- corticosteroid enemas. Colectomy was performed on 7 patients refractory to these treatments. Six patients (4 of them had pancolitis) were treated with cyclosporine (Cys) (4 mg/kg/day, p.o.). Only one patient, a non-responder to Cys therapy, had colectomy. The mean remission time was 4.7 months in 80.6% of patients with extraintestinal involvement and 3.2 months in 71.2% of patients without extraintestinal involvement (P=0.002).

CONCLUSIONS

Medical therapy was generally enough for the treatment. Cys and/or surgery can be another choice for the patients that do not respond to the medical therapy. Extraintestinal manifestations do not change the remission rate, but prolong the time to catch remission.

Liver abscess as a rare complication of Crohn's disease: a case report

Pyogenic liver abscess is a rarely seen extraintestinal complication of Crohn's disease. It has different features from other liver abscesses. Its clinical and laboratory findings are not specific and mimic the reactivation of Crohn's disease and diagnosis can be delayed. The radiological methods are very useful in diagnosis and treatment of liver abscess. In this paper, we present a patient with pyogenic liver abscess which developed in the course of Crohn's disease.

Protective effects of ascorbic acid, dl-alpha-tocopherol acetate, and sodium selenate on ethanol-induced liver damage of rats

In this study, the effect of a combination of vitamin C (ascorbic acid), vitamin E (dl-alpha-tocopherol acetate), and selenium (sodium selenate) on ethanol-induced liver damage in rats was investigated, morphologically and biochemically. The ethanol-induced injury was produced by the administration of 1 mL of absolute ethanol to each rat. Animals received vitamin C (250 mg/kg), vitamin E (250 mg/kg), and selenium (0.5 mg/kg) (ViCESe) for 3 d 1 h prior to the administration of absolute ethanol. In the liver of the animals given ethanol, the degenerative changes such as extreme hyperemia, vacuolization in cells of portal areas, a dilation in sinusoids, mononuclear cell infiltration, a swelling in cisternae of granular endoplasmic reticulum and in mitochondrial cristae, an increase in smooth endoplasmic reticulum, many lipid vacuoles were observed both light and electron microscopically. A similar structure was usually distinguished when compared with control animals, in rats given ethanol + ViCESe. In this group, the findings indicating cellular damage were either not observed at all or were decreased. In the group administered ethanol, a reduction of the blood glutathione (GSH) level and increases in serum values of alanine aminotranserase (ALT), aspartate aminotransferase (AST), lactate dehydrogenase (LDH), alkaline phosphatase (ALP), and gamma-glutamyl transferase (GGT) activities were observed, whereas in the control group, the reverse was found to occur. On the other hand, in the group in which ethanol + ViCESe was administered, it was observed that the blood GSH value and serum ALP and ALT activities increased and serum AST, LDH, and GGT activities decreased. As a result, the present study indicates that ViCESe because of their antioxidant activity against ethanol damage have a protective effect on the liver.

Protective effects of ascorbic acid, DL-alpha-tocopherol acetate, and sodium selenate on ethanol-induced gastric mucosal injury of rats

In this study, the effect of ascorbic acid (vitamin C), DL-alpha-tocopherol acetate (vitamin E), and sodium selenate (selenium) on ethanol-induced gastric mucosal injury in rats was investigated morphologically and biochemically. The gastric mucosal injury was produced by administration of 1 mL of absolute ethanol to each rat. Animals received vitamin C (250 mg/kg), vitamin E (250 mg/kg), and selenium (0.5 mg/kg) for 3 d 1 h prior to the administration of absolute ethanol. In gastric mucosa of rats given ethanol according to control groups, neuronal nitric oxide expression decreased. This immunoreactivity was much lower in the group given ethanol+vitamin C+vitamin E+selenium than the control group and the ethanol-induced group. Scanning electron microscopic evaluation of the ethanol-induced group, when compared to control groups, revealed degenerative changes in gastric mucosa, whereas a good arrangement in surface topography of gastric mucosa in the group given ethanol + vitamin C+vitamin E + selenium was observed. In the group administered ethanol, a reduction of the stomach glutathione (GSH) and serum total protein levels and increases in serum sialic acid, triglycerides, and stomach lipid peroxidation (LPO) levels were observed. Vitamin C+vitamin E+Se administration to alcohol-treated rats significantly increased the serum total protein, triglyceride levels, and stomach GSH levels and significantly lowered the levels of serum sialic acid and stomach LPO compared to untreated alcohol-supplemented rats. As a result of these findings, we can say that the combination of vitamin C, vitamin E, and selenium has a protective effect on ethanol-induced gastric mucosal injury of rats.

Terlipressin and albumin combination treatment in hepatorenal syndrome

OBJECTIVES

Hepatorenal syndrome (HRS) is a severe complication of cirrhosis, leading to death in nearly all of cases in the absence of liver transplantation. Several treatments have been attempted as a bridge to liver transplantation. Promising results have been shown with terlipressin and albumin treatment. The aim of this retrospective study was to evaluate our patients with HRS and the effects of combined therapy of terlipressin and albumin on survival.

PATIENTS AND METHODS

Twenty two patients (15 with type 1 HRS and 7 with type 2 HRS) who were admitted to our clinic between 1996 and 2001, were enrolled. All 7 pts with type 1 HRS were given terlipressin 2-4 mg/day and albumin 2 x 20 g/day for 6 days (range: 3-14).

RESULTS

Rate of mortality in hospital was 64% in total group, 80% in type 1 and 29% in type 2. Additionally rate of death was 57% in type 1 patients that received terlipressin+albumin and 100% in unreceived ones (p<0.05).

CONCLUSION

In this retrospective study, survival following improvement in renal function was noted in nearly half (43%) of type 1 patients that received terlipressin+albumin. Parameters associated with response to terlipressin+albumin and increased survival should be defined better in a large cohort of cirrhotic patients with HRS.

Crohn's disease; analysis of 105 patients

In this paper, 105 patients with Crohn's disease, (47 M, 58 F), mean age 37.4 +/- 42 years were evaluated clinically, demographically and epidemiologically. Mean age of patients at the time of diagnosis was 26.5 +/- 10.9 years. Follow-up period was 2.7 +/- 2.1 years on average. On admission, symptoms or signs were as follows: right lower quadrant pain 90.5%, abdominal mass 18.1%, enterocutaneous fistula 11.4% and subileus 9.5%. Diagnosis of Crohn's disease was established during appendectomy in 14 patients (13.3%). Family history of inflammatory bowel disease was determined only in six patients (5.7%). Intestinal localization were as follows: ileo colonic 52%, ileal 38%, colonic 10%. Clinical forms were inflammatory (68%), fistulous (23%) and obstructive (9%). Sacroiliitis (7.6%), ankylosing spondylitis (4.7%), erythema nodosum (2.9%), pyoderma gangrenosum (1%) were detected as extraintestinal manifestations. Of the patients, 12.4% underwent surgical intervention due to abscess drainage in 6.6%, fistulectomy in 3.8%, stricture resection in 1.9%. Medical therapy alone was sufficient in 75.3% of patients. As a result, our cases mentioned in this paper reflect the general characteristics of Crohn's disease and prominence of regular visits and treatment.

Alverine induced toxic hepatitis: a case report

Drug-induced hepatotoxicity is an important cause of hepatocellular injury. Hepatic necrosis may range from asymptomatic elevations in transaminases to fulminant hepatic failure and death. Alverine is an antispasmodic drug which is especially used in patients with irritable bowel syndrome. Only a few cases of alverine associated hepatotoxicity have been reported previously. We present the case of a patient with alverine induced hepatotoxicity and cholestasis, which has only seldomly been reported in the literature.

Intestinal metaplasia of the gastric cardia: a study from Turkey

BACKGROUND/AIMS

We aimed to investigate the prevalence of intestinal metaplasia in the cardia of a patient group with high incidence of Helicobacter pylori infection presenting for elective upper endoscopy. We also re-evaluated the relation between intestinal metaplasia in the cardia and gastroesophageal reflux disease, smoking, alcohol history, H. pylori infection, Barrett's esophagus and intestinal metaplasia elsewhere in the stomach.

METHODOLOGY

Sixty patients presenting for elective upper endoscopy were included in this study. Prior to undergoing endoscopy each patient was questioned with regard to the clinical indication and symptoms including heartburn, regurgitation, and dysphagia. In addition, a smoking and alcohol history were recorded. Endoscopic biopsies: 1) one from the midantrum on the lesser curvature, 2) one from the incisura angularis, 3) one from the mid-corpus on the lesser curvature, 4) one from the columnar side of the squamocolumnar junction, 5) one from the squamous side of the squamocolumnar junction, 6) one from 2 cm distal to the esophagogastric junction, 7) one from across the squamocolumnar junction. Slides were stained using a combination of hematoxylin-eosin with Alcian blue at pH 2.5 for intestinal metaplasia. Each specimen was examined for the presence of H. pylori.

RESULTS

The prevalence of H. pylori infection was 63%. Prevalence of the H. pylori infection was significantly lower in the patients with intestinal metaplasia of the cardia than in the patients without intestinal metaplasia of the cardia (P = 0.025). There was a positive correlation between the age of the patients and having intestinal metaplasia of the cardia (r = 0.286, P = 0.008). There was no relationship between intestinal metaplasia of the cardia and pyrozis, regurgitation, dysphagia, history of alcohol and smoking esophagitis determined by endoscopy or histopathology, sex, intestinal metaplasia elsewhere in the stomach (P > 0.05).

CONCLUSIONS

The incidence of the intestinal metaplasia of the gastric cardia in Turkey is less than that of western countries. Intestinal metaplasia of the gastric cardia negatively correlates with H. pylori infection. And there was no relationship between gastric cardia intestinal metaplasia and reflux disease. Further investigations are needed for determining the premalign lesion and etiologic factors for cancer of the gastric cardia.

Solitary pancreatic tuberculosis in immunocompetent patients mimicking pancreatic carcinoma

In this study, two cases of biopsy-proven pancreatic tuberculosis are reported. The patients presented with fever, anorexia, fatigue, abdominal pain and weight loss. A differential diagnosis of fever of unknown origin was conducted. Computed tomography (CT) revealed a cystic mass image in the pancreatic head in one patient, and a hypodense lesion in the pancreatic head in the other. The first patient was diagnosed by a wedge biopsy specimen obtained in the exploratory laparotomy. The other patient was diagnosed by percutaneous fine-needle aspiration biopsy. Both patients were successfully treated with quadruple antituberculous therapy for 12 months. We concluded that especially in young patients who present with a mass in the pancreas, pancreatic tuberculosis should be considered among the differential diagnoses, particularly in developing countries and immunosuppressed individuals.

Tuberculous peritonitis--reports of 26 cases, detailing diagnostic and therapeutic problems

OBJECTIVE

To evaluate the clinical presentation, biochemical (ascites and serum) and laparoscopic findings, and to assess the efficacy of triple antituberculous therapy without rifampicin for 6 months in patients with tuberculous peritonitis.

METHODS

Twenty-six tuberculous peritonitis patients (11 male, 15 female) with a mean age of 34.8 +/- 3.4 years (range 14-77) were assessed with regard to diagnostic and therapeutic features.

RESULTS

The most common symptoms and signs were abdominal pain (92.3%) and ascites (96.2%), respectively. Tuberculin skin test (TST) was positive in all patients. An abnormal chest radiography suggestive of previous tuberculosis was present in five patients (19.2%), and two patients (7.7%) had extra-peritoneal (cerebral, pericardial) active tuberculous involvement. In 24 of the 25 patients who underwent laparoscopy with directed biopsy, whitish nodules suggested tuberculous peritonitis; 76% of the biopsy specimens revealed caseating, 20% non-caseating granulomatous inflammation, and 4% non-specific findings. The ascitic fluid of one patient (3.8%) was positive for acid-resistant bacilli, and culture was positive in two patients (7.7%). Twenty-four of the patients were treated for 6 months with isoniazid, streptomycin (total dose 40 g) and pyrazinamide (for the first 2 months and then substituted with ethambutol). Eighteen patients also received methyl prednisolone, initially 20 mg/day, for 1 month. The follow-up period was 19 +/- 1.7 months after the end of therapy (range 6-36). Ascites and abdominal pain abated earlier in patients on steroid therapy. All but two of the 24 patients responded to treatment.

CONCLUSION

Non-invasive tests such as acid-fast stain and culture of the ascitic fluid are usually insufficient, hence invasive laparoscopy and peritoneal biopsy are necessary for the diagnosis of tuberculous peritonitis if non-invasive tests such as ascites adenosine deaminase activity measurement are not easily available. Triple therapy without rifampicin for 6 months is sufficient to treat tuberculous peritonitis.