Birol Baysal

Role of gut microbiota: Obesity and NAFLD

Non-alcoholic fatty liver disease (NAFLD) is a leading cause of chronic liver disease in developed countries. Obesity is the most important risk factor for metabolic syndrome and NAFLD. Accumulated evidence has revealed that gut microbial compositional changes may be associated with more energy harvesting from the diet, which promotes increased fatty acid uptake from adipose tissue and shifts lipid metabolism from oxidation to de novo production. Furthermore, changes in intestinal barrier function contribute to metabolic endotoxemia in the form of low-grade microbial inflammation. Persistent inflammation exacerbates NAFLD progression. In this review, we discuss the role of gut microbiota in obesity and NAFLD.

Pathophysiology, classification and available guidelines of acute pancreatitis

Acute pancreatitis (AP) constitutes the majority of cases requiring hospital admission in gastroenterology. We are yet to know many things about its pathophysiology which is a certain drawback for the progress in its treatment. Prediction of severity is necessary for the plan of the management. The existing scoring systems are yet to be satisfactory. However our progress in the field was significant in the recent decade and a leap forward is expected in this cumbersome-to-manage condition which has many unmet needs. In this review, we are going to summarize the hitherto data in pathogenesis and would weigh the usefulnes and weaknes of each of existing scoring systems in the management of AP.

Roles of serum and biliary CEA, CA19-9, VEGFR3, and TAC in differentiating between malignant and benign biliary obstructions

BACKGROUND/AIMS Despite the presence of many diagnostic methods, the differential diagnosis between benign and malignant biliary obstructions is still not easy. We aimed to evaluate the role of serum/biliary carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA 19-9), vascular endothelial growth factor receptor-3(VEGFR-3), and total antioxidant capacity (TAC) tests in this differential diagnosis. MATERIALS AND METHODS Patients (n:225; 110♂, 115♀) with diagnosis of malignant (n:96) or benign (n:129) biliary obstruction were included in this cross-sectional study. Serum and biliary CEA, CA 19-9, VEGFR-3, and TAC tests were analyzed, statistics were obtained, and significance was defined as p<0.05. RESULTS Mean age was 54.9±16.4 for the benign and 54.2±19.6 for the malignant group (p=0.89). Head of pancreas cancer (18.2%), cholangiocarcinoma (11.4%) and choledochal stone (48%) were the most common etiologies. The area under the curve (AUC)s by ROC analysis of serum/biliary CA 19-9, VEGFR-3, and TAC and serum CEA were 0.701/0.616, 0.622/0.663, 0.602/0.581, and 0713, respectively. Serum TAC had higher sensitivity (61.1%) and CEA had lower sensitivity (42.7%), whereas CEA had higher specificity (89.9%) and TAC had lower specificity (60.5%). In biliary tumor markers, CA 19-9 had higher sensitivity (74%) and VEGFR-3 had lower sensitivity (56.2%); however, VEGFR-3 had higher specificity (79.1%) and CA 19-9 had lower specificity (34.1%). Additionally, combination of serum CEA (p<0.001), CA 19-9 (p<0.001), VEGFR-3 (p<0.001), and biliary CA 19-9 (p=0.028) markers achieved 95% estimation probability, and the sensitivity, specificity, and accuracy were 88.5%, 45.7%, and 64%, respectively. CONCLUSION Serum and biliary CEA, CA 19-9, VEGFR-3, and TAC tests would not be useful in the differentiation between malignant and benign biliary obstructions.

The role of EUS and EUS-guided FNA in the management of subepithelial lesions of the esophagus: A large, single-center experience.

Background: Referral for endosonographic evaluation of subepithelial lesions seen in the gastrointestinal (GI) tract is fairly common. Although rarely studied separately in details, esophageal lesions have some unique differences from other GI sites and might deserve some special considerations regarding follow-up and management. Materials and Methods: All cases referred for endoscopic ultrasound (EUS) evaluation of subepithelial esophageal lesions at Bezmialem University Hospital, a tertiary center in Istanbul, Turkey were retrospectively reviewed. Data were collected for patient and lesion characteristics as well as for pathology results and follow-up if available. Lesions were subcategorized according to their size, location, and final diagnosis. Results: A total of 164 EUS examinations were identified. In 22.5% of cases, the lesion could not be identified by EUS. Of the remaining cases, 57.6% had a lesion larger than 1 cm in size. Extramural compression was the diagnosis in 12% and leiomyoma in around 60%. Thirteen patients had follow-up examinations with only two showing an increase in size after 12 months. Sixty-five EUS-guided fine needle aspirations (EUS-guided FNAs) were performed, with around 50% having nondiagnostic samples and 94% of the remaining samples confirming the presumptive diagnosis. Conclusions: The majority of subepithelial lesions in the esophagus are benign with extremely low malignancy potential. EUS examinations performed for lesions smaller than 2 cm as well as FNAs taken from lesions smaller than 3 cm might have minimal impact on their ultimate management and outcome. More than one FNA pass should be attempted in order to improve the yield.

EUS-guided FNA of a portal vein thrombus in hepatocellular carcinoma

Portal vein thrombosis is a relatively rare but well-known complication of cirrhosis that has a prevalence of between 1% and 5.7%. On the contrary, in case of hepatocellular carcinoma (HCC), it is a much more frequent complication. In this paper, we presented three cases that had liver cirrhosis, mass and portal vein thrombosis in liver. We were not able to diagnose the cases through imaging methods, laboratory results or histopathologically, however, they were diagnosed with endoscopic ultrasonography- fine needle aspiration EUS-FNA from portal vein thrombus.

Visual evoked potentials and pulse wave velocity in inflammatory bowel disease.

BACKGROUND/AIMS Data about the effects of inflammatory bowel disease (IBD) on various functions of the nervous and cardiovascular systems are limited. In this study, the visual neuronal and cardiovascular functions of patients with IBD were evaluated by measuring visual evoked potentials (VEP) and pulse wave velocity (PWV), respectively. MATERIALS AND METHODS There were three study groups: the Crohns disease (CD) group (n=25), the ulcerative colitis (UC) group (n=30), and a healthy control (C) group (n=25). The exclusion criteria were as follows: patients with IBD were in remission, had no extra-intestinal manifestations of the disease, had no additional chronic disease(s), and had been receiving medical treatment for their IBD without any previous surgical intervention. VEP amplitudes (mV) and the N2 and P2 latencies (ms) were recorded for visual-neuronal analysis of all study groups. For cardiovascular assessment in all study groups, PWV was measured noninvasively as follows: the carotid-femoral PWV with the Complior Colson device (The authors have no conflict of interest.) and the PWV along the aorta with two ultrasound strain-gauge pressure-sensitive transducers (TY-306 Fukuda pressure-sensitive transducers - Fukuda Denshi Co, Tokyo, Japan) fixed transcutaneously over the course of a pair of arteries separated by a known distance. The right femoral and right common carotid arteries were the ones used. RESULTS The PWV levels of the CD and UC groups were significantly higher than those in the C group (p<0.001). In the bilateral recording of the VEP, the N2 latencies of the CD (p<0.05) and UC (p<0.01) groups were significantly longer than those in the C group. CONCLUSION In this study, we showed vascular and visual neuronal impairments at a subclinical stage in patients with both types of IBD.

Staging of rectal carcinoma: MDCT, MRI or EUS. Single center experience

BACKGROUND/AIMS To retrospectively compare the efficacy of multidetector computed tomography (MDCT), magnetic resonance imaging (MRI) and endosonography (EUS) in the staging of rectal carcinoma. MATERIALS AND METHODS A total of 50 patients (36 male, 14 female) were included in the study. The data from surgical staging were used as reference for comparing the yield of EUS, MRI, and MDCT in preoperative T and N staging of rectal carcinoma. Comparisons were based on the chi-square test. RESULTS The mean age+SD of the patients were 60±12 years (range; 28-80). The distribution of rectal tumors according to the T and N staging in surgical pathology was as following: T1 (n:2), T2 (n:15), T3 (n:22), T4 (n:11); N0 (n:22), N1-2 (n:28). The accuracy rate of EUS was statistically higher than that of MDCT (92% vs 64%; p<0.01) and that of MRI (92% vs 72%; p<0.01) for T2 tumors. For T3 tumors, EUS had statistically better accuracy of staging compared to MDCT (90% vs 58%; p<0.01) and MRI (90% vs 60%; p<0.01). As for T4 tumors, the accuracy rate of EUS was higher compared to MRI (98% vs 80%; p<0.01). There was no statistical difference in accuracy rates for detection of lymph nodes across the modalities (EUS, 84%; MDCT 76%; MRI 70%; p=not significant). CONCLUSION EUS appears more accurate in T staging compared to MDCT and MRI in rectal carcinoma. Regarding nodal staging, performance of EUS, MDCT and MRI are similar.

Olanzapine-induced acute pancreatitis

A 44-year-old man with schizophrenia was started on olanzapine 1 year ago. After 6 weeks, olanzapine was changed to amisulpride 400 mg/day because of abdominal pain. However, the etiology of abdominal pain was not investigated. After 10 months, olanzapine was readministered at 10 mg/day because of an increase in obsessive symptoms. During the third week of treatment, the patient developed severe abdominal pain radiating back, with nausea and vomiting. His family history was unremarkable. He did not consume alcohol or drugs and was a non-smoker. Physical examination revealed tachycardia and tachypnea, with a blood pressure of 110/70 mmHg and oxygen saturation of 95%. The patient had a fever of 38.2°C. Abdominal examination revealed mild distension with tenderness. Blood test revealed the following: glucose: 181 mg/dL, amylase: 1552 U/L, lipase: 2138 U/L, CRP: 3.2 mg/dL, WBC: 15,550 mm3, hematocrit: 36%, and platelets: 366,000 mm3. Computed tomography examination revealed diffuse enlargement of the pancreatic parenchyma with peripancreatic fluid collection. There was no biliary abnormality. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography revealed there was no biliary tract abnormality. Olanzapine was discontinued and intravenous fluids and analgesics were administered. After 1 week, the patient was discharged with complete resolution of symptoms.

Concurrent acute pancreatitis and pericardial effusion

While pleural effusion and ascites secondary to acute pancreatitis are common, clinically relevant pericardial effusion and cardiac tamponade are observed rarely. In a study by Pezzilli et al., pleural effusion was noted in 7 of the 21 patients with acute pancreatitis whereas the authors detected pericardial effusion development in only three. The authors asserted that pleural effusion was associated with severe acute pancreatitis, while pericardial effusion and the severity of acute pancreatitis were not significantly related.

Interferon Induced Focal Segmental Glomerulosclerosis

Behçets disease is an inflammatory disease of unknown etiology which involves recurring oral and genital aphthous ulcers and ocular lesions as well as articular, vascular, and nervous system involvement. Focal segmental glomerulosclerosis (FSGS) is usually seen in viral infections, immune deficiency syndrome, sickle cell anemia, and hyperfiltration and secondary to interferon therapy. Here, we present a case of FSGS identified with kidney biopsy in a patient who had been diagnosed with Behçets disease and received interferon-alpha treatment for uveitis and presented with acute renal failure and nephrotic syndrome associated with interferon.