Bulent Yasar

Oxidative Stress in Helicobacter pylori Infection: Does Supplementation with Vitamins C and E Increase the Eradication Rate?

Aim:  This study aims to assess the antioxidant property of vitamins E and C in Helicobacter pylori infection, and to determine if adding them to standard triple therapy plus bismuth subcitrate increases the H. pylori eradication rate.

Administration of olive oil followed by a low volume of polyethylene glycol-electrolyte lavage solution improves patient satisfaction with right-side colonic cleansing over administration of the conventional volume of polyethylene glycol-electrolyte lavage solution for colonoscopy preparation

BACKGROUND Proper bowel cleansing before colonoscopy is essential for satisfactory evaluation of the colon. The required consumption of a large volume of salty-tasting liquid, 4 L of polyethylene glycol-electrolyte lavage solution (PEG-ELS), is the primary limitation to achieving this goal. OBJECTIVE To achieve better patient satisfaction with efficient bowel cleansing, we compared the effects of the conventional volume (4 L) of PEG-ELS with those of a low volume (2 L) in combination with pretreatment using different laxatives, such as magnesium hydroxide (milk of magnesia) and olive oil. DESIGN Randomized, controlled study. SETTING A single research hospital. PATIENTS Patients undergoing elective colonoscopy. INTERVENTIONS A total of 120 patients were randomized to 1 of 3 different preparation regimens: 39 patients were prepared with a conventional volume (4 L) of PEG-ELS (Preparation [Prep] 1), and the remaining patients were prepared with a lower volume (2 L) of PEG-ELS and pretreatment with a laxative, either 15 g of magnesium hydroxide (40 patients, Prep 2) or 60 mL of olive oil (41 patients, Prep 3) 3 hours before PEG-ELS administration. MAIN OUTCOME MEASUREMENTS The primary outcome was the efficacy of colonic cleansing on the left and right sides. Secondary outcomes were patient satisfaction and side effects. RESULTS The olive oil regimen (Prep 3) resulted in significantly more adequate bowel cleansing of the right colon than administration of the conventional volume of PEG-ELS (Prep 1) and the magnesium hydroxide (Prep 2) regimen (97.6% vs 74.5% and 72.5%, respectively, P = .007). However, this difference was not observed in the left colon (91.5%, 85.5%, and 91.8% for Preps 1, 2, and 3, respectively, P = .776). When asked, 38 patients (95%) taking Prep 2, 35 patients (85.3%) taking Prep 3, and only 11 patients (28.2%) taking Prep 1 preferred the same preparation regimen if they required a future colonoscopy (P =.006), based on ease of use and taste. The side effects were comparable in each group. LIMITATIONS The limitations of this study include the relatively small sample size, the single-center study design, and the use of a nonvalidated symptom scoring system. CONCLUSION Pretreatment with olive oil before administration of a low volume of PEG-ELS enhances both patient satisfaction and the quality of right-side colonic cleansing over the administration of the conventional volume of PEG-ELS for colonoscopy preparation. Although the magnesium hydroxide regimen (Prep 2) was the preferred regimen in this study, its colonic cleansing effectiveness was not as great as those of the other regimens. Based on our results, the olive oil regimen is recommended, especially for patients who are not able to consume large volumes of liquids, such as the elderly, and those who are suspected of having subtle right-side colonic lesions.

The diagnostic accuracy of the Forns index, platelet count and AST to Platelet Ratio Index derived fibrosis index for the prediction of Hepatitis C virus-related significant liver fibrosis and cirrhosis

Abstract Aim. To provide a simple fibrosis index combining the routine laboratory markers for predicting significant fibrosis (SF) and cirrhosis in patients with chronic HCV. Methods. Platelet count, ALT, AST, AST to ALT Ratio, AST to Platelet Ratio Index (APRI), Forns index, FIB-4 and Age Platelet Index of 202 liver biopsy performed HCV-infected patients were reviewed. METAVIR classification was used to determine the stage of liver fibrosis. The predictive fibrosis index was constructed by multiple linear regression analysis (− 2.948 + 0.562 × Forns index + 0.288 × APRI + 0.006 × platelet count [109/L]). Results. Median (25th–75th interquartile range) age was 52 (42–59) years, and 61% were male. 65.8% (n = 133) had SF (F2–F4) and 23.3% (n = 47) had cirrhosis (F4). For discrimination of SF, AUROCs were: Fibrosis index = 0.869, Forns index = 0.837, APRI = 0.814, platelet count = 0.764. For cirrhosis, AUROCs were: Fibrosis index = 0.911, Forns index = 0.883, APRI = 0.847, platelet count = 0.827. A cut-off point of ≤ 1.2 for fibrosis index excluded SF in 89% of patients with sensitivity of 96%, while > 2.0 predicted SF in 88% of patients with specificity of 86%. Threshold of ≤ 1.9 excluded cirrhosis in 95% of patients with sensitivity of 94%, while > 2.7 showed cirrhosis in 88% of patients with specificity of 95%. In multivariate logistic regression analysis, OR (95% CI) of fibrosis index was 7.825 (3.682–16.629) for SF (p < 0.001) and was 8.672 (4.179–17.996) for cirrhosis (p < 0.001). Conclusion. SF and cirrhosis were predicted with accuracy of 82% and 89% and were excluded with accuracy of 74% and 82% using this fibrosis index which may potentially decrease the need for liver biopsy in 76% and 83% of patients, respectively.

A case of mediastinal fibrosis due to radiotherapy and ‘downhill’ esophageal varices: a rare cause of upper gastrointestinal bleeding

Abstract‘Downhill’ varices are located in the proximal part of the esophagus. Their etiology differs from the distal types, with most of them usually being related to superior vena cava obstruction. Although bleeding due to ‘downhill’ varices is very rare, it can be life-threatening. Here, we present a case of upper gastrointestinal bleeding due to mediastinal fibrosis associated with chest radiotherapy for seminoma metastasis sixteen years previously, which was successfully treated conservatively.

Glutaraldehyde-induced colitis: three case reports

Glutaraldehyde (2% solution) is an effective and widely used disinfecting solution for cold sterilization of endoscopic instruments. Direct contact of glutaraldehyde solution with colonic mucosa can cause self-limited colitis. As it rarely occurs as a complication of colonoscopy, glutaraldehyde-induced colitis is generally reported only as case reports in the literature. We report three cases of glutaraldehyde-induced colitis after colonoscopy. All lesions resolved with supportive treatment. We stress the need for thorough rinsing of the surface and channels of the endoscope with water to avoid the occurrence of this complication.

Effect of the mucolytic erdosteine on the success rate of PPI-based first-line triple therapy for Helicobacter pylori eradication: a prospective, double-blind, randomized, placebo-controlled study.

Abstract Objective. Because Helicobacter pylori creates a well-sheltered microenvironment within the gastric mucus layer, it has been speculated that the disruption of this space by a mucolytic agent may enhance the eradication rate. The aim of the present study was to investigate the effect of erdosteine, a strong mucolytic agent, on the effectiveness of PPI-based, first-line triple therapy in the eradication of H. pylori. Material and methods. Initially, 196 patients were enrolled to the study. Of these, 79 H. pylori-positive patients were randomized to the erdosteine group (triple therapy consisting of pantoprazole, amoxicillin and clarithromycin plus erdosteine; n = 40) or the placebo group (triple therapy plus placebo; n = 39) for 14 days. Endoscopic biopsies and 13C-urea breath tests were performed at entry and at 4–6 weeks after the completion of the treatment. Additionally, rapid urease tests were performed at entry. Results. The eradication of H. pylori was achieved in 30 (75%) of the 40 patients in the erdosteine group and in 20 (51.3%) of the 39 patients in the placebo group, according to the ITT analysis (p = 0.028). When the PP analysis was performed as well, H. pylori eradication was achieved in 30 (78.9%) of the 38 patients in the erdosteine group and in 20 (52.6%) of the 38 patients in the placebo group (p = 0.016). Conclusions. Erdosteine is an efficient adjuvant therapy that could be used in conjunction with first-line triple therapy in the treatment of H. pylori.

Re-determining the cut-off points of FIB-4 for patients monoinfected with chronic hepatitis B virus infection

Abstract Objective: This study aimed to determine significant liver fibrosis and cirrhosis with different FIB-4 cut-off points, and the need for liver biopsy (LB) by optimizing the initially established cut-off points of 1.45 and 3.25. Materials and methods: The study included 201 patients monoinfected with chronic HBV. METAVIR classification was used to determine the stage of fibrosis. ROC analysis and the Youden index were performed to define the optimum cut-off points. Results: A FIB-4 cut-off point of 1.45 and 1.62 generated Youden indexes of 0.51 and 0.55, the accuracy of 78.6% and 81.1% for significant liver fibrosis, respectively. The FIB-4 cut-off was set at 2.40 and 3.25 Youden indexes were 0.46 and 0.16, accuracies were 79.6% and 69.7% for significant liver fibrosis, respectively. A cut-off point of 1.45 and 1.62 for FIB-4 generated Youden indexes of 0.62 and 0.66, the accuracies of 81.6% and 84.1% for cirrhosis, while the FIB-4 cut-off point of 2.40 and 3.25 generated Youden indexes of 0.59 and 0.22, with the accuracies of 90% and 84.1% for cirrhosis, respectively. Conclusions: The FIB-4 cut-off points of 1.62 and 2.40 have higher accuracy and may decrease the need for LB 12% more than the initially established ones in HBV monoinfected patients.

Extramedullary relapse of multiple myeloma presenting as massive upper gastrointestinal bleeding: a rare complication.

To the Editor, Multiple myeloma (MM) is a malignant disease of terminally differentiated B cells presenting with bone lesions, renal failure, infections, anemia, hypercalcemia, and hyperviscosity syndrome. The malignant plasma cells are usually confined to the bone marrow in MM. Extramedullary plasmacytoma (EMP) accounts for 4% of all plasma cell malignancies. EMP mainly occurs in the respiratory tract (82.2%), with gastrointestinal (GI) tract involvement in less than 5% of all EMP cases. The small bowel is the most common site of GI involvement, followed by the stomach, colon, and esophagus [1]. Here, we report a 69-year-old patient, admitted to hospital with hematemesis and melena, and finally diagnosed with massive upper GI bleeding caused by gastric plasmacytoma. A 69-year-old male presented at the Emergency Unit with hematemesis and melena. He was known to have a history of MM and had previously been treated with vincristine, doxorubicin, and dexamethasone therapy with a very good partial response. The patient underwent emergent esophagogastroduodenoscopy. There was fresh blood in the lumen, oozing from an ulcerated, multilobulated mass 3 × 3 cm in diameter occupying the greater curvature of the proximal corpus (Forrest 1B). In addition, there were many separated polypoid, ulcerated masses about 1 cm in diameter in the body of the stomach (Fig. 1). The bleeding was successfully ablated with adrenaline injection and heater probe cautery. The patient was treated with intravenous fluids, proton pump inhibitors, erythrocytes, and fresh frozen plasma suspensions in the intensive care unit. A repeat endoscopy was performed 48 hours later, which revealed the previously identified gastric masses without evidence of bleeding. Biopsies were obtained from the lesions. The pathology specimens showed diffuse atypical plasma cell infiltration with prominent staining for CD38 and lambda immunostains leading to a pathological diagnosis of plasmacytoma (Figs. 2 and ​and33). Figure 1 Endoscopic view of the gastric plasmacytomas. Figure 2 Gastric mucosa with diffuse atypical plasma cell infiltration (H&E, ×40). Figure 3 Immunostained section shows diffuse and strong reactivity for CD38 (×200). Extramedullary involvement, particularly involvement of the GI tract, is rare in MM. Most patients with gastric plasmacytomas are elderly and often present with nonspecific GI symptoms, including anorexia, weight loss, abdominal pain, vomiting, and rarely GI bleeding, usually from an ulcerated lesion. Intestinal obstruction or malabsorption may be the presenting symptom in patients with colonic or small bowel involvement [2]. On endoscopy, gastric plasmacytomas present as nodular ulcerated masses and occasionally irregular thickened gastric folds that can mimic gastrointestinal stromal tumor, lymphoma, or carcinoma [3]. The diagnosis is based on morphology and immunohistochemical demonstration of monoclonal kappa and lambda light chains or heavy chains found in plasma cells [4]. Although the treatment of EMP has not been standardized, managing mass-related local complications such as bleeding or bowel obstruction is critical in these patients. Surgery and irradiation with or without chemotherapy might be other treatment options [5]. Once GI involvement is present, the prognosis is very poor despite aggressive therapy. Consequently, although very rare, gastric plasmacytoma should be kept in mind in a patient with GI bleeding and atypical endoscopic lesions, especially those with a history of hematologic malignancy.