Aydın Şeref Köksal

Long-term Efficacy and Safety of Lamivudine, Entecavir, and Tenofovir for Treatment of Hepatitis B Virus–Related Cirrhosis

BACKGROUND & AIMS Data are limited on the efficacy and safety of tenofovir and entecavir when given for more than 1 year to patients with hepatitis B-related cirrhosis. We investigated the long-term safety and efficacy of these antiviral drugs in patients with chronic hepatitis B virus (HBV) infection, with compensated or decompensated cirrhosis, and compared results with those from lamivudine. METHODS We performed a retrospective analysis of data from 227 adult patients with chronic HBV infection who were diagnosed with cirrhosis, beginning in 2005, at 18 centers throughout Turkey. There were 104 patients who had decompensated cirrhosis, and 197 patients were treatment naive before. Seventy-two patients received tenofovir (followed up for 21.4 ± 9.7 mo), 77 patients received entecavir (followed up for 24.0 ± 13.3 mo), and 74 patients received lamivudine (followed up for 36.5 ± 24.1 mo). We collected data on patient demographics and baseline characteristics. Laboratory test results, clinical outcomes, and drug-related adverse events were compared among groups. RESULTS Levels of HBV DNA less than 400 copies/mL were achieved in 91.5%, 92.5%, and 77% of patients receiving tenofovir, entecavir, or lamivudine, respectively. Levels of alanine aminotransferase normalized in 86.8%, 92.1%, and 71.8% of patients who received tenofovir, entecavir, and lamivudine, respectively. Child-Turcotte-Pugh scores increased among 8.5% of patients who received tenofovir, 15.6% who received entecavir, and 27.4% who received lamivudine. Frequencies of complications from cirrhosis, including hepatic encephalopathy, variceal bleeding, hepatocellular carcinoma, and mortality, were similar among groups. Lamivudine had to be changed to another drug for 32.4% of the patients. CONCLUSIONS Tenofovir and entecavir are effective and safe for long-term use in patients with compensated or decompensated cirrhosis from HBV infection.

Endoscopic closure of gastrointestinal defects with an over-the-scope clip device. A case series and review of the literature

BACKGROUND The over-the-scope clip (OTSC) is a novel endoscopic tool used in the non surgical treatment of gastrointestinal perforations, fistula, and anastomotic leaks. AIMS The aim of the present study was to evaluate the therapeutic efficacy of this new endoscopic device on anastomotic postsurgical leak and fistulas or GI perforation in a tertiary referral center. PATIENTS AND METHODS The study group consisted of nine patients (three female, six male, age: 22-65 years). The indications were anastomotic leak in five patients, fistula in three patients, and perforation in one patient. Atraumatic version of OTSCs with medium sized caps, twin graspers and anchor were used. All of the patients were treated with only one OTSC. None of the patients underwent additional endoscopic treatments. RESULTS The median size of the defects were 15 mm (range 5-20 mm). OTSC was favourable in five of nine patients (three with leak, and one with fistula and perforation, each). OTSC could not be deployed or partially closed the defect in the remaining four patients because of fibrosis at the edges of the defect. Excluding the case with perforation, the median time elapsed between the diagnosis and the placement of OTSC was 35 days (range: 20-80) in the successful group and 70 days (range: 38-94) in the unsuccessful group. There were no complications due to the OTSC application or the applicator cap. CONCLUSIONS OTSC is a safe and effective device for closure of perforations and leaks. However therapeutic efficacy is lower in cases with fistulas mainly due to associated fibrosis at the borders.

A simple method to improve adenoma detection rate during colonoscopy: Altering patient position

BACKGROUND Colonoscopy is currently considered to be the gold standard method for detecting and removing adenomatous polyps. However, tandem colonoscopy studies reveal a pooled polyp miss rate of 22%. OBJECTIVE A prospective randomized trial was conducted to assess whether alteration of patient position during colonoscopy withdrawal increases the adenoma detection rate (ADR). METHOD The study group included 120 patients who presented for elective colonoscopic examination. After reaching the cecum, patients were randomly assigned in a 1:1 ratio to examination in either the left lateral position or other positions (left lateral position for the cecum, ascending colon and hepatic flexure; supine for transverse colon; and supine and right lateral position for splenic flexure, descending and sigmoid colon) first. Examination of the colon was performed segment by segment. The size, morphology and location of all polyps were recorded. Polyps were removed immediately after examination of a colon segment when all positions were completed. ADR and polyp detection rates (PDR) were calculated. RESULTS A total of 102 patients completed the study. Examination in the left lateral position revealed 66 polyps in 31 patients (PDR 30.3%) and 42 adenomas in 24 patients (ADR 23.5%). PDR increased to 43.1% (81 polyps in 44 patients) and the ADR to 33.3% (53 adenomas in 34 patients) after the colon was examined in the additional positions (P<0.001 and P=0.002, respectively). The increase in the number of adenomas detected was statistically significant in the transverse and sigmoid colon. The addition of position changes led to a 9.8% increase in the ADR in the transverse colon, splenic flexure, and descending and sigmoid colon. The frequency of surveillance interval was shortened in nine (8.8%) patients after examination of the colon in dynamic positions. CONCLUSION Alteration of patient position during colonoscopy withdrawal is a simple and effective method to improve ADR.

Isolated splenic vein thrombosis: An unusual cause and review of the literature

Isolated obstruction (mainly due to thrombosis) of the splenic vein usually results in left-sided portal hypertension and isolated fundal varice formation. This syndrome is a rare cause of gastrointestinal bleeding. Pancreatic diseases are among the most common etiologies of splenic vein obstruction. Renal disorders are rarely reported as a cause of splenic vein thrombosis. In the present article, a case of a 26-year-old woman with a perirenal abscess presenting with gastrointestinal bleeding as a complication of an isolated splenic vein thrombosis is described. The thrombosis could not be visualized with ultrasonography and angiography because of its extremely proximal localization. Fundal varices disappeared following splenectomy and nephrectomy. Follow-up at one year revealed the patient to be well both clinically and endoscopically.

Probable Sulbactam/Ampicillin–Associated Prolonged Cholestasis

OBJECTIVE To present a single case of sulbactam/ampicillin–induced chronic cholestasis and a literature review of antibiotic-associated chronic cholestasis. CASE SUMMARY A 74-year-old man with Hodgkins disease in remission developed severe and prolonged cholestasis after treatment with sulbactam/ampicillin 750 mg twice daily for 7 days. All other etiologies, including Hodgkins disease, were appropriately ruled out and the cholestasis was ascribed to sulbactam/ampicillin treatment. The patient improved gradually and became asymptomatic 7 months after the last dose of sulbactam/ampicillin. According to the Naranjo probability scale, sulbactam/ampicillin was the probable cause of the cholestasis. DISCUSSION Ampicillin, a semisynthetic penicillin, has rarely been associated with hepatic injury when used alone. Hepatocellular and acute cholestatic injury due to ampicillin have been described. Cholestasis secondary to sulbactam/ampicillin use has not been previously reported. CONCLUSIONS Sulbactam/ampicillin, one of the most widely used antibiotics, may cause chronic cholestatic hepatitis. Clinicians should be aware of this adverse affect and consider it during diagnostic workup of liver injury.

Alfuzosin-Induced Acute Hepatitis in a Patient with Chronic Liver Disease

OBJECTIVE: To report a new case of probable alfuzosin-induced hepatitis. CASE SUMMARY: An 80-year-old man was evaluated because of jaundice and pruritus. He was diagnosed as having Child-Pugh A chronic liver disease due to hepatitis B virus. Other etiologies of hepatitis were appropriately ruled out, and the hepatitis B was non-replicative. Therefore, elevated liver enzyme levels were ascribed to alfuzosin treatment. DISCUSSION: Although alfuzosin-related mixed-type hepatotoxicity has been previously reported, this is the first published case describing probable hepatocellular-type hepatotoxicity resulting from use of alfuzosin in a patient with underlying chronic liver disease. According to the Naranjo probability scale, alfuzosin was a probable cause of the hepatotoxicity. The mechanism of alfuzosin-induced liver damage is unknown. Several features, such as absence of predictable dose-dependent toxicity of alfuzosin in previous studies and absence of hypersensitivity manifestations in our case, are suggestive of a metabolic type of idiosyncratic toxicity. CONCLUSIONS: Alfuzosin rarely causes hepatotoxicity; however, clinicians must be alert for this adverse effect while using alfuzosin.

Clinical and histological features of idiosyncratic liver injury: Dilemma in diagnosis of autoimmune hepatitis

Drug‐induced liver injury (DILI) is becoming a worldwide problem with its still unexplained properties.

Propranolol-exacerbated mesenteric ischemia in a patient with hyperthyroidism.

OBJECTIVE: To report a case of acute mesenteric ischemia associated with the use of oral propranolol. CASE SUMMARY: A 59-year-old white man was admitted to the hospital with chronic diarrhea and weight loss. The patient was diagnosed as having hyperthyroidism. Therapy with propylthiouracil 100 mg 3 times daily and propranolol 20 mg twice daily was initiated on an outpatient basis. The following day, the patient was readmitted to our hospital with increased abdominal pain and bloody diarrhea. Angiography revealed superior mesenteric artery occlusion. Antegrade aorta-mesenteric bypass surgery was performed for revascularization, and the patient was discharged 10 days after the surgery. The patient was well both clinically and endoscopically at a follow-up visit 8 months later. DISCUSSION: Although mesenteric ischemia is a devastating illness of varied causes, drug-associated mesenteric ischemia is rarely seen. By decreasing cardiac output and selective vasodilatory receptor inhibition in the splanchnic circulation, propranolol can cause a decline in splanchnic blood flow. An objective causality assessment indicated that propranolol was the possible cause of the arterial occlusion. CONCLUSIONS: Propranolol may rarely be associated with mesenteric ischemia. In cases of newly developed acute abdomen undergoing propranolol therapy, physicians should be aware of this rare and serious adverse reaction to this drug.

An unusual presentation of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) metastasis to the lymph nodes has been reported in about one-third of autopsies, mostly to the regional chains. Involvement of cervical lymph nodes is extremely rare. We encountered an unusual case of HCC in a patient with chronic liver disease presenting with right-sided anterior cervical lymph node metastasis skipping mediastinal and supraclavicular chains. One should be aware of that unusual site of presentation and metastasis of HCC so as not to miss the diagnosis.

Crohn's and Behçet's disease association presenting with superior vena cava thrombosis

A 21-year-old male patient with a 6-year history of Crohn’s disease presented with shoulder pain and edema in the neck and bilateral supraclavicular fossa. Color Doppler ultrasonography and computed tomography scan revealed bilateral thrombosis of the external jugular veins, brachiocephalic veins, and superior vena cava. Other etiologies were appropriately ruled out and the thrombosis was initially attributed to Crohn’s disease. In the follow-up, the patient developed recurrent, painful orogenital ulcers and acne vulgaris-like skin eruptions. HLA tissue typing was HLA B-51. The diagnosis of Crohn’s disease associated with Behçet’s disease was made. Although there are several case reports describing such an association, a Medline research revealed that this was the first presentation of such an association with thrombosis. Thrombosis in unusual sites may reflect the uncommon association of Crohn’s disease with hypercoagulable conditions such as Behçet’s disease.