Baris Yilmaz

Mean platelet volume as a fibrosis marker in patients with chronic hepatitis B

Introduction: Many noninvasive tests have been studied for the diagnosis and determining the liver fibrosis score (LFS). In this study, we aimed to research the correlation of mean platelet volume (MPV) and stage of liver fibrosis in patients with chronic hepatitis B (CHB). Patients and Methods: Fifty‐nine patients with CHB were enrolled retrospectively into the study. Age–sex matched 25 healthy subjects were used as control group. The following data were obtained from computerized patient registry database: HBV‐DNA level, hepatitis B e‐antigen seropositivity, liver enzymes and function tests, white blood cell count, platelet count, hemoglobin, histological activity index, LFS, and MPV. Patients were divided into two groups: patients without significant fibrosis (F0, F1, or F2) (Group 1) and patients with advanced fibrosis (F3, F4) (Group 2). Results: A statistically significant increase in MPV was seen in patients with CHB compared with healthy controls (8.49±0.84 fl vs.7.65±0.42 fl, P<0.001). Receiver operating characteristic curve analysis suggested that the optimum MPV level cut‐off points for CHB was 8.0 fl, with sensitivity, specificity, PPV, and NPV of 68, 76, 86, and 50%, respectively. MPV levels were significantly higher in Group 2 (8.91±0.94 fl, P: 0.009) compared with Group 1 (8.32±0.74 fl). ROC curve analysis suggested that the optimum MPV level cut‐off points for Group 2 was 8.45 fl, with sensitivity, specificity, positive and negative predictive value of 77, 59, 45, and 85%, respectively. Multivariable logistic regression model, which consisted of HAI, ALT, HBV‐DNA, platelet count, and MPV, was performed. We showed that MPV was independently associated with advanced fibrosis (P: 0.031). Conclusion: We suggest that MPV might help in the assessment of fibrosis in CHB. It should not be considered a stand‐alone test for this use owing to nonspecificity with other diseases. J. Clin. Lab. Anal. 25:162–165, 2011.

Mean platelet volume could be possible biomarker in early diagnosis and monitoring of gastric cancer.

Abstract Gastric cancer is the fourth most frequent cancer and the second cause of cancer-related deaths worldwide. The early diagnosis of gastric cancer is fundamental in decreasing the mortality rates. It has been shown that MPV level is a sign of inflammation in hepatocellular carcinoma and pancreatic adenocarcinoma. The aim of this study is to examine whether MPV would be a useful inflammatory marker for differentiating gastric cancer patients from healthy controls. Thirty-one gastric cancer patients and 31 age-sexes matched healthy subjects included into the study. Patients with hypertension, hematological and renal disease, heart failure, chronic infection, hepatic disorder and other cancer were excluded from the study. MPV level was significantly higher in pre-operative gastric cancer patients compared to healthy subjects (8.31 fL vs. 7.85; p: 0.007). ROC analysis suggested 8.25 fL as the cut-off value for MPV (AUC: 0.717, sensitivity: 61%, specificity: 81%). Surgical tumor resection resulted in a significant decrease in MPV level (8.31 fL vs. 7.55 fL; p: 0.001). No significant difference was found in MPV level between the post-operative group and control subjects. We did not find statistically significant difference between MPV and TNM stages. In conclusion, changes in MPV values may be used as an easily available biomarker for monitoring the healthy patients for GC risk and may prompt physicians to make an early diagnosis of GC.

Mean platelet volume in the diagnosis and prognosis of Crimean-Congo hemorrhagic fever.

Introduction: Crimean–Congo hemorrhagic fever (CCHF) is a viral tick-borne zoonosis, which is a severe illness, causing hemorrhages in humans. Mean platelet volume (MPV) is used as a surrogate marker of platelet function and has been shown to be a sign of inflammation. The objective of the present study is to examine the association between MPV and CCHF. We also aimed to investigate the association between MPV and coagulopathy markers in the mortality rates and prognosis of patients with CCHF. Patients and Methods: Ninety-three patients with CCHF were enrolled retrospectively into the study and 15 of them were excluded according to the exclusion criteria. Twenty-five healthy individuals were included as a control group which was age and gender matched with CCHF patients. We compared the levels of MPV between the patient and the control groups. We also compared the coagulopathy markers of fatal CCHF patients (n = 9) with nonfatal cases (n = 69). Results: Platelet counts were significantly lower in the CCHF group. Levels of international normalized ratio (INR), prothrombin time (PT), and activated partial thromboplastin time (aPTT) were significantly higher in CCHF group (P < .001, <.001, <.001, respectively). A statistically significant increase in MPV was observed in patients with CCHF compared with healthy controls (8.63 ± 1.23 fL vs 7.65 ± 0.42 fL, P < .001). Receiver–operating characteristic curve analysis suggested that the optimum MPV level cutoff points for patients with CCHF was 8.15 fL, with a sensitivity and specificity of 65% and 88%, respectively. The MPV levels were not significantly different between group 2 (nonsurvivor) and group 1 (survivor). However, platelet count, d-dimer, INR, PT, and aPTT were also positively correlated with the mortality rates (P = .008, <.001, <.001, <.001, and <.001, respectively). Multivariable logistic regression model showed an independent correlation between MPV and mortality rate (P < .001). Conclusion: In conclusion, MPV may be a beneficial marker in the diagnosis of CCHF, especially in cases with thrombocytopenia, the MPV levels are high. We also conclude that MPV may independently predict the prognosis of patients with CCHF.

Unusual cause of acute gastrointestinal bleeding: gastric pyogenic granuloma.

Pyogenic granuloma (PG) is a benign, polypoid type of lobular capillary hemangioma that presents as a polypoid red mass. The lesion is found most commonly on the skin and in the oral cavity. It is extremely rare in the alimentary tract, other than in the oral cavity. Here, we report a case of PG identified in the stomach associated with acute bleeding. A 64-year-old man was admitted to our emergency room with a complaint of hematemesis and melena. Physical examination revealed no remarkable abnormalities other than conjunctival paleness.At the time of admission his laboratory findings were as follows: hemoglobin 10 g/dL, hematocrit 28.5%. An upper gastrointestinal endoscopy revealed a pedunculated reddish lesion approximately 8 mm in diameter with an irregular surface in the cardia of the stomach. Blood was leaking from the surface of the lesion (Fig. 1). The lesion was resected using a polypectomy snare. Histological examination of the resected specimen revealed many capillaries of various sizes, lined with plump endothelial cells, accompanied by acute and chronic inflammatory infiltrates. The endothelial cells proved to be immunohistochemically positive for CD34 (Fig. 2).The histological features were consistent with those of a PG. No bleeding was noted following endoscopic resection of the lesion. Anemia was resolved by treating with iron. PG is an acquired benign tumor arising from the blood vessels of the skin or mucosa, polypoid form of capillary hemangioma.To date, a few cases of PG of the digestive tract have been reported, particularly in the colon, ileum, and esophagus. Only two cases have been described in the stomach. To our knowledge, this is the second case report of gastric PG presenting with acute gastrointestinal bleeding. In conclusion, PG should be considered in the differential diagnosis of acute gastrointestinal bleeding.

Unusual Cause of Upper Gastrointestinal Hemorrhage: Spontaneous Dissection of the Celiac Trunk

To the Editor: A 56-year-old man was admitted to our hospital with hematemesis and melena for 3 hours. He had also a history of upper abdominal pain after meal for 6 months and no any diseases. His vital signs were within normal limits. Physical findings were normal, but rectal examination revealed melena. Laboratory tests showed unremarkable findings and also hemostasis parameters were normal. Endoscopy revealed pulsatile submucosal arterial vascular collaterals with nipple sign in stomach [Figure 1]. There was a small amount of fresh blood in stomach, but no active bleeding. He was treated conservatively and remained asymptomatic in follow-up. Abdominal-enhanced computed tomography (CT) showed dissection of the celiac trunk and enhancement perigastric and gastric intramural vascular collaterals due to chronic ischemia caused by celiac artery dissection [Figure 1]. Figure 1 Endoscopic image of the pulsatile submucosal arterial vascular collaterals with nipple sign in the stomach (a), computed tomography (CT) angiographic image of dissection of the celiac trunk and perigastric and gastric intramural vascular collaterals (b ... Spontaneous dissection of the celiac trunk is uncommon and is rarely considered in the diagnosis of upper gastrointestinal (GI) hemorrhage. Its complications are ischemia to the supplied organs, aneurysm, and rupture.[1] To our knowledge, no cases of GI hemorrhage caused by celiac artery dissection are reported in the medical literature. Hence, we firstly report a case with upper GI hemorrhage caused by spontaneousdissectionof the celiac trunk.

Adding Pineapple Juice to a Polyethylene Glycol-Based Bowel Cleansing Regime Improved the Quality of Colon Cleaning

Background/Aims: An unsuccessful colonoscopy procedure is often related to inadequate bowel cleansing. It is difficult for patients to finish the whole 4 liters of polyethylene glycol-electrolyte lavage (PEG-EL) because of its salty taste and the large quantity. Pineapple juice has been shown to be an effective agent in the dissolution of undigested food in the stomach. This study assessed the effectiveness of both 2 and 4 liters of PEG-EL in precolonoscopic bowel cleansing and the quality of colonoscopic cleaning by adding 1 liter of pineapple juice to a reduced-volume PEG-based regime. Methods: The patients were chosen from those undergoing a colonoscopic procedure. A total of 126 patients were randomized into 3 groups receiving 3 different PEG-EL (Golytely®) regimes, i.e. 4 liters of PEG-EL (group 1, n = 44), 2 liters of PEG-EL (group 2, n = 39) or 2 liters of PEG-EL with 1 liter of pineapple juice (Dimes® 100%; group 3, n = 43). Results: Both the 4- and 2-liter PEG-EL regimes resulted in similar bowel cleansing scores in all parts of the colonic segments. However, adding 1 liter of pineapple juice to the reduced-volume PEG-EL regime improved the quality of the cleansing on the right side of the colon and in the transverse colon. Adequate bowel cleansing was achieved in 68.1% of the patients in group 1, 63.9% in group 2 and 80% in group 3 (the lowest score in one of the segments). On the other hand, the tolerability of the regimes was similar in all 3 groups (p = 0.509). Conclusions: Reduced PEG-EL (2 rather than 4 liters) may be sufficient for precolonoscopic bowel cleansing in the Turkish population. Administration of pineapple juice in the reduced-dose preparation regime may improve the quality of the bowel cleaning.

Ulcerative colitis triggered by pegylated interferon alone therapy for chronic hepatitis C

To the Editor: Interferon (IFN) alpha, a therapy not only for chronic viral hepatitis but also for multiple sclerosis, some solid tumors, and myeloproliferative disorders, was described as a trigger of some autoimmune disorders. Since ulcerative colitis (UC) is a chronic inflammatory disease, the role of IFNs on the treatment of UC was investigated. Here we describe a UC patient with a diagnosis of chronic hepatitis C (HCV) after IFN therapy. A 34-year-old woman was admitted to the hospital due to bloody diarrhea. She had a history of a routine hemodialysis program for 14 years. Bloody diarrhea 5 to 7 times a day and abdominal cramps relieved by defecation were started after three doses of weekly pegylated IFN use due to the chronic HCV. Clinical examination was unremarkable except for high bowel sounds (no sign of abdominal tenderness or fever). Routine blood tests were: aspartate aminotransferase (AST) 56 (U/L) (0–40), alanine aminotransferase (ALT) 45 (U/L) (0–41), alkalene phosphatase (ALP) 247 (U/L) (0–270), gammaglutamyl transpherase (GGT) 45 (U/L) (0–55), total protein 7.9 g/L (6.4–8.3), albumin 3.7 g/dL (3.8–5.1), and total bilirubin (T Bil) 0.6 mg/dL (0–1), creatinine 0.8 mg/dL (0.9–1.3), hemoglobin 13.2 g/dL, leukocytes 7.6 10/mL, platelet 176 10/ mL, sedimentation rate 45 mm/hour, and C-reactive protein 3 mg/dL. The stool examination for ova, parasites, cultures, and Clostridium difficile toxin were all negative. In her history she had no surgery or any medication use. She denied taking any herbal drugs, alcohol abuse, or risk factors for sexually transmitted diseases. Colonoscopic examination showed diffuse hyperemia and edematous area with exudates, ulcerations, and fragility starting from the descending colon to the anorectal area. The biopsies from the mucosa described above revealed UC. Pegylated IFN was discontinued and mesalazine was prescribed at a dose of 2 g per day. The symptoms were relieved in the following days and control colonoscopy revealed mucosa healing by the third month of therapy. A recent meta-analysis revealed that IFN therapy in UC remission is not beneficial. However, physicians face problems in patients with both UC and chronic HCV. In spite of both remission and induction of UC with the use of IFN being reported before, Bargiggia et al treated chronic active HCV patients with inactive, or mildly active UC, and none of them developed a UC relapse under IFN therapy, 12 months thereafter, in contrast to the cases mentioned above. The case reports of an exacerbation of UC attributed to IFN were under both standard IFN alone, and PEG-IFNþ ribavirin. Also, the date of relapse and region of active colitis were all different from each other (varying from 1 day after initiation of therapy to 7 days after stopping, and from rectum to total colonic disease). Most of the patients became well after the discontinuation of IFN and starting of mesalazine alone, or mesalazine with short-term steroid. In conclusion, IFN therapy without ribavirin can be a predisposing factor for UC exacerbation, especially in therapy-naı̈ve patients.

M30 Does Not Predict the Severity of Hepatosteatosis, Whereas Adiponectin Level Declined With Increase of ALT and the Severity of Hepatic Steatosis

Nonalcoholic fatty liver disease (NAFLD) is an emerging problem all over the world. Because NAFLD and polycystic ovary syndrome (PCOS) are both closely related with insulin resistance, it would be necessary to determine the rate of presence of NAFLD in PCOS patients. So, this study aimed to investigate the utility of M30 in PCOS patients for the diagnosis of hepatic injury.

Rare complication of ulcerative colitis: aseptic nasal septal abscess.

To the Editor: Nasal septal abscess is described as a collection of purulence between the nasal septum and the mucoperichondrium or mucoperiosteum. To date, this condition has not been reported as a complication of ulcerative colitis (UC). Here we present a patient with UC accompanied by a nasal septal abscess which resolved with abscess drainage as well as steroid therapy. This is the first case report of a nasal septal abscess in a patient with UC to the best of our knowledge. A 34-year-old woman was admitted to otorhinolaryngology clinic with complaints of a 2-week history of nasal ache, difficulty with nasal breathing, and fever. The nasal examination of the patient at presentation in the Ear, Nose, and Throat Clinic revealed nasal soft tissue swelling compatible with a nasal septal abscess (Fig. 1). After drainage of the abscess, she was treated with appropriate empiric antibiotics as well as abscess drainage several times for 2 weeks, although blood and abscess cultures were negative. However, the abscess did not resolve with drainage and antibiotics. She consulted our clinic for bloody diarrhea up to 8 times a day for 3 weeks. In her past medical history she had pan-UC for 12 years. She was under treatment with only 5-aminosalicylic acid products. Physical examination showed minimal diffuse tenderness of the abdomen without rebound and defense. Stool examination revealed white blood cells, red blood cells, no ova, or parasites. Entamoeba histolytica antigens in stool was negative. Colonoscopic examination revealed that all of the colonic mucosa was erythematous, granular, and friable. It had exudates and macroscopic ulcers. Histopathological findings were compatible with UC. The erythrocyte sedimentation rate was 75/hour, C-reactive protein 167 mg/L. Other laboratory findings were normal. A direct radiograph of the patient was normal. Based on the clinical and laboratory findings of the patient, the diagnosis was suspected to be an acute aseptic nasal septal abscess associated with active UC. She was therefore treated with 1 mg/kg/day of oral prednisone. After 7 days of steroid therapy the abscess resolved and active colitis has been in remission. Also, acute phase reactants normalized after 5 days. UC is a chronic idiopathic inflammatory disease of the gastrointestinal tract involving the large bowel. Patients with UC usually present with extraintestinal manifestations affecting the skin, eyes, mouth, joints, and liver. Many complications that parallel disease activity frequently improve with successful treatment of the UC. Although many complications have been described in patients with UC, a nasal septal abscess associated with UC has not been reported before. Many extraintestinal complications of UC (e.g., pyoderma gangrenosum) can resolve with steroid treatment, particularly severe cases. In conclusion, in patients presenting with active UC and nasal symptoms, aseptic nasal septal abscess should be kept in mind as an extraintestinal manifestation of UC, especially pan-UC.

Acute Tubulo-Interstitiel Nephritis Associated with Diffuse Large B-Cell Lymphoma Presenting as Acute Renal Failure

Renal infiltration in malignant lymphomas may involve the interstitium but rarely causes acute renal failure. In this report, we describe a 59-year-old woman presenting with an acute renal failure due to bilateral diffuse large B-cell non-Hodgkins infiltration of the kidneys.